Family Medicine · panel 412 · PRV-1001
A. Whitfield, MD — high-level metrics
HCC recapture
91%
Chronic conditions recaptured YTD
Open care gaps
74
0.18 per attributed patient
Forms returned
92%
268 of 290 pre-visit forms
30-day readmission
17.1%
Rolling 12 months
IP admits / last 30d
5
32 ED visits last 90 days
AWV completion
88%
Annual wellness visits closed
Appointments — Thu, Sep 18
9 scheduled patients
21 open gaps · 21 suspected HCCs · 4 with an IP admit in last 30 days
| Time | Patient | Visit type | Open gaps | Suspected HCCs | IP 30d | ED 90d | RAF | Flags |
|---|---|---|---|---|---|---|---|---|
| 8:00 AM | Cecil Moreau MRN-404076 · 75y | Post-discharge follow-up | 4 Blood pressure control, Diabetic eye exam, Med adherence — diabetes, HbA1c control | 1 HCC 327 — CKD stage 4 | 2 | 0 | 1.666 | TOCCare mgmtForm returned |
| 8:30 AM | Harold Sorensen MRN-552975 · 64y | Post-discharge follow-up | 3 Statin therapy, Med adherence — diabetes, Annual wellness visit | 2 HCC 280 — COPD, HCC 48 — Morbid obesity | 1 | 0 | 1.750 | TOCForm returned |
| 9:00 AM | Rufus Sandoval MRN-976454 · 70y | Annual wellness visit | 2 HbA1c control, Annual wellness visit | 3 HCC 151 — Major depression, HCC 18 — Diabetes w/ complications, HCC 226 — CHF | 0 | 0 | 1.795 | Form returned |
| 10:30 AM | Gloria Ramirez MRN-241605 · 73y | Post-discharge follow-up | 2 HbA1c control, Diabetic eye exam | 3 HCC 48 — Morbid obesity, HCC 151 — Major depression, HCC 18 — Diabetes w/ complications | 1 | 0 | 0.791 | TOCCare mgmtForm pending |
| 11:00 AM | Rosalind Abernathy MRN-989377 · 80y | Hypertension follow-up | 2 Diabetic eye exam, Blood pressure control | 2 HCC 48 — Morbid obesity, HCC 280 — COPD | 0 | 1 | 2.178 | Care mgmtForm returned |
| 11:30 AM | Alvin Iyer MRN-602342 · 89y | Diabetes management | 2 Colorectal screening, Diabetic eye exam | 3 HCC 280 — COPD, HCC 18 — Diabetes w/ complications, HCC 48 — Morbid obesity | 0 | 0 | 1.731 | Form returned |
| 12:00 PM | Clifford Calloway MRN-994749 · 89y | Post-discharge follow-up | 2 HbA1c control, Annual wellness visit | 3 HCC 226 — CHF, HCC 48 — Morbid obesity, HCC 151 — Major depression | 1 | 0 | 2.104 | TOCForm returned |
| 1:30 PM | Mabel Sandoval MRN-439373 · 79y | Chronic care follow-up | 1 Diabetic eye exam | 1 HCC 151 — Major depression | 0 | 0 | 1.750 | Form pending |
| 2:00 PM | Juanita Nguyen MRN-113397 · 67y | Diabetes management | 3 Diabetic eye exam, Colorectal screening, HbA1c control | 3 HCC 280 — COPD, HCC 151 — Major depression, HCC 327 — CKD stage 4 | 0 | 1 | 2.104 | Care mgmtForm returned |
Sample data shown for layout review — figures are illustrative.