Rheumatology APCM Care Plan Documentation Checklist

Specify ICD-10 codes for RA, SLE, or PsA, including seropositivity status and current disease activity scores like CDAI or RAPID3.

Record associated conditions such as interstitial lung disease, cardiovascular risk, or osteoporosis common in chronic inflammatory patients.

Document the patient's ability to perform activities of daily living (ADLs) and any mobility aids required due to joint damage.

Note dietary habits, exercise routines, and smoking status, which significantly impact inflammation and medication efficacy.

Include PHQ-9 or GAD-7 results to address the high prevalence of depression and anxiety in chronic autoimmune patients.

Identify barriers to care such as transportation for infusions or financial constraints affecting specialty drug access.

List all DMARDs, biologics, and biosimilars, including dosage, frequency, and administration method (SQ vs IV).

Document required intervals for CBC, LFTs, and Creatinine based on ACR guidelines for specific immunosuppressants.

Ensure annual screening results for latent infections are documented for patients on TNF inhibitors or JAK inhibitors.

Track Shingrix, Pneumovax, and annual flu shots, ensuring they are administered prior to starting high-level immunosuppression.

Use AI-driven call logs to document reports of injection site reactions, infections, or gastrointestinal distress.

Record the preferred specialty pharmacy and last refill date to prevent gaps in biologic therapy.

Establish patient-specific criteria for what constitutes a flare versus expected daily stiffness or pain.

Document the workflow for urgent steroid tapers or bridge therapy when flares occur between scheduled visits.

Set up automated phone triggers that escalate reports of fever or severe joint swelling directly to the clinical team.

Outline the use of NSAIDs, topical agents, or non-pharmacological interventions for breakthrough pain.

Provide documented instructions on joint protection and rest during periods of high disease activity.

Ensure all non-face-to-face time spent on care coordination, including AI-managed follow-up calls, is logged.

Document that the patient or caregiver has received a copy of the care plan and it is available in the EHR 24/7.

Verify that the patient has provided written or verbal consent for APCM services and understands potential cost-sharing.

Record communications with ophthalmology (for Plaquenil users) or pulmonology to ensure holistic care.

Document the status and expiration dates of PAs for biologics to avoid treatment interruptions.

Schedule and document a comprehensive review of the care plan at least once every 12 months.