Medicare Care Plan Template - Medicare Care Plan (Cognitive Assessment and Care Plan Template)

Sep 23, 2026

Upload by James

Medicare Care Plan template for primary care use, combining cognitive assessment with a structured written care plan. Covers cognitive problem severity, type of dementia, and next follow-up date, with options for advance care planning, diagnostic testing (including biomarkers and neuroimaging), neurology/psychiatry referral, and aging in place versus assisted living. Includes action planning for neurologic, behavioral, medical, caregiver, and safety needs, plus recommended medications, labs, immunizations, therapies, and legal/financial support.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Cognitive Assessment and Written Care Plan

Care Plan Details

Cognitive Problems

Neurological, Mental Health, Behavioral, and Functional Problems

Medical Problems

Caregiver Assistance

Performing a Cognitive Assessment and Developing a Care Plan in Primary Care1-4 Full abbreviations, accreditation, and disclosure information available at [PeerView.com/XUM40](PeerView.com/XUM40) Cognitive Assessment and Care Plan (CPT 99483) Template | CACP_10: Written care plan Today’s date: Next follow-up date: | | | | --- | --- | --- | | Cognitive problems | Actions | | | ❑ None
❑ Mild cognitive impairment
❑ Mild dementia
❑ Moderate stage
❑ Late stage Type of dementia ❑ Alzheimer’s
❑ Vascular
❑ Mixed
❑ Lewy Body
❑ Frontotemporal
❑ Other
❑ Unknown; need further evaluation | ❑ Advance care planning (living wills, family meeting)
❑ Additional diagnostic testing (check all that apply)❑ Biomarker testing:
❑ Neuroimaging: MRI
❑ Neuroimaging: CT
❑ Neuroimaging: Amyloid PET
❑ Neuroimaging: Other
❑ Referral to neurologist/psychiatrist/ geriatrician:
❑ Aging in place planning vs assisted living ❑ Driving safely
❑ Exercise your body
❑ Exercise your brain (remediation, hobbies, games, computer, volunteering) | ❑ Healthy diet (dietician if needed, Meals on Wheels)
❑ Lab testing: CBC/CMP/TSH/B12/folate/RPR/ HIV/Other
❑ Legal/financial planning (power of attorney, guardianship, advance directives)
❑ Medication: donepezil/rivastigmine/galantamine/ memantine/donepezil + memantine
❑ Medication: aducanumab/lecanemab
❑ Medications to avoid (sleep aids, diphenhydramine)
❑ Social engagement (clubs, church, sports) | | Neurological, mental health, behavioral, functional problems | | | | ❑ Aggression
❑ Delusions
❑ Depression/suicide
❑ Hallucinations
❑ Decision making (capacity)
❑ Safety
❑ Sleep | ❑ Alcohol avoidance
❑ Autonomy promotion
❑ Counseling
❑ Driving safety
❑ Environmental “rounds”
❑ Exercise
❑ Home safety
❑ Medications: antidepressants/antipsychotics/
anxiolytics/other: | ❑ Music therapy
❑ Reminiscence therapy
❑ Relaxation therapy (art, pets, yoga,
muscle relaxation)
❑ Sleep patterns
❑ Structure
❑ Support group
❑ Other | | Medical problems | | | | ❑ Lung disease ❑ Heart disease
❑ Parkinson’s disease ❑ Vision and/or hearing
❑ Swallowing
❑ Cancer ❑ Dental
❑ Kidney disease
❑ Liver disease
❑ Gastrointestinal
❑ Urologic
❑ Other | ❑ Cardiac rehabilitation
❑ Dental care
❑ Fall prevention
❑ Hearing/vision evaluation
❑ Hospice care
❑ Immunizations (flu, pneumococcal, tetanus booster, shingles)❑ Incontinence
❑ Physical/occupational therapy evaluation
❑ Pulmonary rehabilitation
❑ Speech therapy evaluation
❑ Other: | | | Caregiver assistance | | | | | ❑ Adult day care
❑ Aging in place (home modification)❑ Alzheimer’s Association ❑ Assistance from other resources
(clubs, church, family, coworkers)❑ Barriers to assistance
❑ Behavior management skills
❑ Communication skills
❑ Disease-specific resources ❑ Environmental management
❑ Home aides
❑ Hospice | ❑ Legal/financial planning
❑ Memory/communication aids (clock, calendar, glasses, hearing aids, pictures)
❑ Medical/practical supplies ❑ Medication management
❑ Safety planning (guns, stairs, home hazards, falls)❑ Self-care actions
❑ Senior alert system
❑ Support group | 1. [https://www.alz.org/media/Documents/Cognitive-Impairment-Care-Planning-Toolkit_012623.pdf. 2. Borson S et al.](https://www.alz.org/media/Documents/Cognitive-Impairment-Care-Planning-Toolkit_012623.pdf. 2. Borson S et al. Alzheimers Dement. 2017)[ Alzheimers Dement](https://www.alz.org/media/Documents/Cognitive-Impairment-Care-Planning-Toolkit_012623.pdf. 2. Borson S et al. Alzheimers Dement. 2017)[. 2017](https://www.alz.org/media/Documents/Cognitive-Impairment-Care-Planning-Toolkit_012623.pdf. 2. Borson S et al. Alzheimers Dement. 2017);13:1168-1173. 3. Form adapted from [https://www.aafp.org/fpm/2019/0100/p1](https://www.aafp.org/fpm/2019/0100/p1)1.html. 4. [https://Champio

FAQs

What sections are included in the written care plan template?

The template organizes a written care plan into cognitive problems, neurological/mental health/behavioral/functional problems, medical problems, and caregiver assistance, each with selectable actions.

How does the template guide diagnostic testing and specialist referrals?

It lists diagnostic options such as biomarker testing and neuroimaging (MRI/CT/Amyloid PET) and provides checkboxes for referral to a neurologist, psychiatrist, or geriatrician.

What care actions are suggested for dementia-related safety and daily living?

It includes guidance on advance care planning, driving safety, exercise and diet, home safety and environmental “rounds,” sleep pattern support, medication management, and caregiver planning such as legal/financial support and safety planning.

Sep 23, 2026

Upload by James