APCM Care Plan Documentation for Allergy & Immunology

Document current triggers, peak flow zones, and step-up/step-down therapy adjustments during monthly APCM check-ins.

Use AI-assisted calls to verify patient adherence and correct usage of MDIs or DPIs as part of chronic care monitoring.

Track and record the frequency of albuterol or other SABA/SMART therapy usage to determine asthma control levels.

Document patient efforts in reducing exposure to dust mites, pet dander, or seasonal pollen as discussed in monthly updates.

Assess and document the impact of allergic rhinitis or GERD on asthma control during regular care plan updates.

Record compliance with SCIT schedules and any local or systemic reactions reported since the last clinical encounter.

Document daily adherence to sublingual immunotherapy and any oral mucosal symptoms reported via automated check-ins.

For patients on Xolair, Nucala, or Dupixent, document symptom improvement and any injection site reactions.

Verify the patient has an unexpired epinephrine auto-injector and understands when to use it during every APCM cycle.

Update the care plan with any history of anaphylaxis or near-fatal asthma events to maintain high-risk monitoring status.

Perform a comprehensive review of all allergy medications, including OTC antihistamines and nasal corticosteroids, to prevent interactions.

Document specific instructions for managing chronic urticaria or eczema flares, including topical steroid ladders.

For immunodeficiency patients, document infusion schedules, trough levels, and any infection-related hospitalizations.

Update documentation on accidental ingestion risks and emergency contact protocols for patients with severe food allergies.

Integrate automated call logs into the EHR to prove 20+ minutes of non-face-to-face care for APCM billing compliance.