Healthcare Performance Summary

HEALTHCARE PERFORMANCE SUMMARY

This Healthcare Performance Summary provides an objective record of recent clinical measurements, care-plan progress, preventive care status, and targeted recommendations. It is prepared for Patient and intended to be reviewed by the patient and the clinical care team. The patient should review for accuracy and sign to acknowledge receipt and consent for internal care-team sharing as described in the HIPAA Acknowledgment below.

Patient Information

Male Female Non-binary Prefer not to disclose

Provider and Report Details

Report Date:   Reporting Period From: To:

Clinical Measurements & Vitals

Blood Pressure: / mmHg on

Height:    Weight:    BMI:

Pulse:    Temperature:    Respiratory Rate:    SpO2:

Medications, Allergies, and Medical History

Chronic Condition Management & Quality Measures

Diabetes: Most recent HbA1c: on

Hypertension control: Average BP during period:   Medication adjustments:

Lipids: Most recent LDL: on

Depression Screening (PHQ-9): Score: on

Smoking Status: Current Former Never

Preventive Care & Immunizations

Influenza vaccination up-to-date:    Pneumococcal up-to-date:

Last colorectal cancer screening:   Last mammogram:

Medication Adherence & Self-Management

Patient-reported medication adherence: Adherent Non-adherent

Care Plan Goals and Progress

Assessment, Recommendations, and Follow-up

Recommended follow-up appointment:

HIPAA Acknowledgment and Authorization

I acknowledge that I have received or been offered information regarding privacy practices governing the use and disclosure of my protected health information. I understand this summary will be included in my medical record. By signing below I acknowledge receipt of this Healthcare Performance Summary and authorize internal sharing of the information contained herein among members of my treating care team for purposes of treatment, care coordination, and quality improvement.

Authorization to share with external providers or entities beyond the treating care team requires additional written authorization unless otherwise permitted by law.

Acknowledgment of receipt and authorization:

Authorization expiration (if applicable):

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