CCM Clinical Tool

Chronic Care Management · Reference & Analyzer

Select a condition to begin

Pick a condition from the list for its ICD codes, medications by line, problem-note template, and gap checker.

29conditions
817ICD-10 codes
435medications

Medication Analyzer

Enter an ICD-10 code and paste the patient's medication list from PointClickCare. The tool identifies which medications treat that condition (with line of therapy), which are for other conditions, and flags any contraindications — all offline, no data leaves your device.

Type the condition's ICD code (e.g. I10, E11, I50)
Paste the full medication list from PCC (copy-paste)

LOINC Code Reference

LOINC (Logical Observation Identifiers Names and Codes) for each lab in the "Numbers to Track". Click any code to copy it. Use these when documenting lab results in the EMR.

Progress Notes Generator

Paste the raw progress notes copied from PointClickCare. The tool finds the signed provider notes that contain an Assessment & Plan, pulls the Date of Service and provider, and writes them out in the follow-up format — ready to copy. Nursing and unsigned notes are excluded and listed so nothing is dropped silently. Runs entirely offline — no data leaves your device.

Copy the progress notes from PCC (from the last DOS till the date of your FU) and paste them here

Problem Note Generator

Approved wording from the Update Care Policy sheet. Tick what applies, fill any blanks, then copy each section into the matching field in PCC.

Follow-Up Templates

Ready-to-copy templates used in the follow-up workflow. Click Copy on any template, then fill in the bracketed placeholders. Use the search box or category filter to find one fast.

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v143 · Meds: 662, unchanged. Monitoring periods updated from Mohamed's Update Care Policy sheet (12 Oct): weight 30 d, warfarin INR 28 d, cognitive assessment 90 d, DEXA 730 d, CAD lipids 180 / BP 1, PHQ-9 30 d for Pain & Cancer, RF / anti-CCP / pneumococcal no expiry, plus periods for Hyperthyroidism, Dementia PHQ-9 and the BH and heart pages that had none. Same values in the Mini Gap Checker and the Recency column · 13 Oct 2026