Epic EHR APCM Care Plan Documentation Checklist

Build a custom Epic registry using Clarity or Reporting Workbench to identify patients with multiple chronic conditions eligible for APCM.

Use Healthy Planet to flag APCM-eligible patients on the schedule and within the patient header for immediate visibility.

Link AI call center triggers to registry updates so new eligible patients receive automated introductory calls about the APCM program.

Ensure Epic risk adjustment factor (RAF) scores are accurately mapped to the APCM registry logic to prioritize high-need patients.

Configure SmartForms to exclude patients already enrolled in conflicting CCM or RPM programs to avoid billing errors.

Create standardized SmartPhrases for care managers that pull in diagnosis lists and medication orders directly from the Epic chart.

Customize the Care Plan activity in Epic to include required APCM elements like goals, barriers, and interventions.

Use Epic SmartForms to capture structured data for functional and cognitive assessments required for APCM compliance.

Integrate SDOH wheels within the care plan to track non-clinical factors impacting the patient chronic care progress.

Ensure the care plan is configured to automatically push updates to the MyChart portal for patient review and signature.

Configure the AI call center to push transcript summaries directly into Epic as Telephone Encounters or General Notes.

Set up triggers where an AI-handled call results in an automated MyChart message confirming care plan changes.

Use AI voice workflows to capture and timestamp verbal APCM consent, documenting it automatically in the Epic Media tab.

Ensure AI-driven outreach time is automatically logged toward the monthly APCM time requirements within the Epic billing module.

Configure the AI agent to route complex clinical questions from calls directly to the Epic In Basket of the assigned care manager.