Urology APCM Care Plan Documentation Checklist

Document lower urinary tract symptoms (LUTS) and current International Prostate Symptom Score (IPSS).

Identify low-risk patients on active surveillance requiring structured PSA monitoring and follow-up.

Flag patients requiring metabolic workups and long-term hydration or dietary management.

Note persistent symptoms requiring pharmaceutical intervention or third-line therapies.

Confirm active Medicare Part B coverage and obtain documented verbal or written patient consent.

Set measurable targets for AUA-SI scores or nocturia frequency reductions.

Outline protocols for alpha-blockers, 5-ARIs, or anticholinergics, including side effect monitoring.

Document specific dietary restrictions and 24-hour urine collection schedules.

Define the frequency of lab work for post-prostatectomy or active surveillance patients.

List clinical 'red flags' such as gross hematuria or acute urinary retention for immediate triage.

Deploy AI agents to conduct monthly check-ins on symptom stability and medication adherence.

Use AI voice interactions to capture IPSS or OAB-q scores between office visits.

Automate calls for upcoming PSA tests or metabolic stone panels to ensure compliance.

Ensure all automated patient interactions are logged directly into the EHR for audit protection.

Use AI to filter urgent urologic issues from routine refill requests after clinic hours.

Document at least 20 minutes of clinical staff time spent on care coordination per month.

Ensure a copy of the electronic care plan was provided to the patient or caregiver.

Confirm the patient has a documented pathway for 24/7 urgent care access.

Review and revise the care plan at least once every 12 months or upon clinical change.

Ensure APCM codes are not billed on the same day as major urologic surgical procedures.