APCM Care Plan Documentation Checklist for Sleep Apnea

Document the baseline Apnea-Hypopnea Index or Respiratory Disturbance Index from the diagnostic PSG or HST.

Explicitly document how OSA impacts current hypertension, atrial fibrillation, or Type 2 Diabetes in the patient record.

Record the baseline ESS score to measure the severity of daytime somnolence and track improvements over time.

Include neck circumference, Mallampati score, and BMI as physiological indicators of airway obstruction risk.

Note any previous attempts at surgery, positional therapy, or oral appliances that failed or were discontinued.

Document usage data for the 30-day period within the first 90 days (goal: >4 hours/night for 70% of nights).

Log the treated AHI from machine downloads to ensure the current pressure settings are effectively resolving events.

Record average leak rates to determine if a mask refitting or change in headgear is required to maintain therapy.

Track the dates for mask, filter, and tubing replacements to ensure hygiene and prevent mechanical failures.

Document adjustments to ramp time, pressure relief, and humidity levels used to increase patient comfort.

Configure AI call triggers for when machine data shows usage dropping below 4 hours for three consecutive nights.

Use AI voice agents to ask about morning headaches, dry mouth, and daytime fatigue during monthly intervals.

Review and document the use of sedatives, narcotics, or alcohol which may exacerbate sleep-disordered breathing.

For patients using MADs, document monthly adjustments and subjective improvement in snoring or gasping.

Log progress in weight loss programs or referrals to bariatric specialists as part of the OSA care plan.