APCM Care Plan Documentation Checklist for Geriatrics

Cross-reference Medicare records to identify Qualified Medicare Beneficiaries for higher G0558 reimbursement tiers.

Record initial cognitive assessment results to tailor future phone-based AI check-ins and determine caregiver involvement.

Secure and document verbal or written consent specifically for longitudinal care management services and AI monitoring.

Document the legal proxy or primary family contact for patients with cognitive impairment or dementia for communication routing.

Identify transportation or housing issues that impact medication adherence and appointment attendance for the elderly.

Complete a full polypharmacy review, documenting all prescriptions, OTCs, and potential interactions common in seniors.

Document recent falls and home safety evaluations to trigger automated preventive check-ins via AI call handling.

Record the patient's ability to perform activities of daily living to determine the level of remote care support needed.

Update and document end-of-life preferences, DNR status, and medical power of attorney in the electronic record.

Monitor and document weight changes and dietary restrictions relevant to chronic conditions like CHF or diabetes.

Use AI call records to document all interactions with family members regarding the patient's care plan changes.

Document coordination efforts with ALF staff for medication administration and wellness monitoring protocols.

Record recent consultations with cardiologists, neurologists, or physical therapists to ensure care plan continuity.

Document referrals to Meals on Wheels or local senior centers as part of the holistic social care approach.

Ensure all hospital discharge summaries are reviewed and integrated into the APCM care plan within 48 hours.