Diabetes APCM Care Plan Documentation Checklist

Confirm the patient has active Medicare Part B and is not currently enrolled in conflicting care management programs.

Ensure at least two chronic conditions are documented, such as Type 2 Diabetes and Hypertension or Obesity.

Input the most recent HbA1C lab result (within 90 days) to establish a starting point for the APCM care plan.

Evaluate the patient's ability to perform finger-stick tests or use a CGM and administer insulin if required.

Screen for social determinants of health, such as food insecurity or lack of transportation, that impact diabetes control.

Document names, dosages, and frequencies for Metformin, SGLT2 inhibitors, GLP-1 agonists, or other medications.

For insulin-dependent patients, record basal/bolus schedules and specific sliding scale instructions.

Document any history of severe hypoglycemic events and the patient's access to emergency glucagon.

Outline the criteria and steps for adjusting medication doses between face-to-face office visits.

Set up AI call handling to prompt patients for weekly medication adherence updates and log responses in the EHR.

Document the date and results of the last dilated retinal exam to monitor for diabetic retinopathy.

Record findings from monofilament testing and check for skin breakdown or signs of neuropathy.

Ensure annual Urine Albumin-to-Creatinine Ratio and eGFR testing are scheduled and documented.

Establish and document target BP goals (typically <130/80) to mitigate cardiovascular risk in diabetic patients.

Sync Continuous Glucose Monitor data into the APCM record to identify time-in-range trends.

Document specific carbohydrate goals and referrals to Registered Dietitians or DSME programs.

Record the patient's agreed-upon exercise plan, such as 30 minutes of brisk walking five days per week.

If the patient uses tobacco, document the offer of cessation resources to reduce vascular complications.

Confirm the patient understands the 'Rule of 15' for treating low blood sugar episodes.

Utilize automated phone outreach to provide seasonal tips on foot care and healthy holiday eating.