APCM Documentation Checklist: Obesity & Weight Management

Record baseline BMI ≥30 (or ≥27 with comorbidities) to establish medical necessity for APCM.

Secure and document verbal or written patient consent specifically for APCM services in the EHR.

List secondary conditions like Sleep Apnea, HTN, or Osteoarthritis driven by the patient's obesity.

Develop a shared electronic care plan addressing weight goals and metabolic health markers.

Use AI call logs to identify patients inquiring about weight loss meds for proactive APCM enrollment.

Document the specific titration path and patient tolerance for each dosage increase.

Record patient reports of nausea, vomiting, or GI distress gathered during monthly AI check-in calls.

Document pharmacy availability issues and the clinical coordination efforts to find alternative fills.

Track HbA1c, lipid panels, and kidney function tests required for metabolic drug monitoring.

Verify all current medications to avoid contraindications with prescribed weight-loss pharmacotherapy.

Document progress at 3, 6, 12, and 24-month post-surgical intervals for Medicare compliance.

Log patient compliance with required bariatric multivitamins, calcium, and protein intake.

Set clinical triggers in the care plan for review if the patient shows >5% weight regain.

Document the absence or presence of dumping syndrome or nutrient deficiencies during monthly calls.

Record referrals or follow-ups with behavioral health specialists for emotional eating management.

Use AI call logs to document time spent on non-face-to-face care coordination and counseling.

Document system-generated alerts for GLP-1 refills to ensure patient medication continuity.

Capture and log weight data and satiety levels reported by patients during AI-led check-ins.

Log patient inquiries handled by AI regarding acute medication side effects during nights/weekends.

Track and document follow-up attendance for Intensive Behavioral Therapy (IBT) sessions.