Review and finalize an APCM care plan

After you enroll a patient in Advanced Primary Care Management (APCM), aflow drafts an initial care plan from their chart. A clinician reviews and edits the draft in the aflow side panel, then accepts it.

How the draft is created

aflow starts the draft as soon as the patient is enrolled, and it's usually ready within an hour. It uses chart information from about the last 12 months, such as the problem list, recent visit notes, and documents like lab results and consult letters. The draft includes:

• A section for each chronic condition that drives the patient's care, with its ICD-10 code and short, patient-friendly plan lines. Lines are usually labeled Treatment, Self-care, Monitoring, Watch for, or Follow-up.
• Standing guidance: general guidance that appears in every plan.
• Compliance: statements about how APCM requirements are met.
• Sources: the chart data and documents the draft was built from.

Review and edit the draft

1. On the patient's APCM card, select Review on the Initial care plan row. You can also select APCM at the top of the side panel and choose the patient under Care plan reviews.
2. Read each diagnosis section and edit the plan text directly. Select a diagnosis name to change it, select Add Dx to add one, or hover over a section and select the X to remove it. Use Additional notes for guidance that isn't tied to a diagnosis.
3. Open Standing guidance and Compliance, and make sure every statement is accurate for this patient and your practice. Compliance edits apply to this note only.
4. Check Sources. Some sources open the original document.
5. If conditions are missing, or the draft says No chronic conditions found on this chart, select Add context (or Context in the care plan header). Describe the patient's conditions and history, then select Save & update draft. Your edits are kept, and accepting is paused until the updated draft arrives.

Every diagnosis needs plan text before you can accept. Add a plan or remove the diagnosis.

Finalize the care plan

The button at the bottom of the review depends on how your practice is set up:

• Accept care plan records your review and makes this the patient's current care plan.
• Push & accept appears if your practice pushes APCM notes to the EHR. First open the patient's chart and a progress note in your EHR. aflow writes the note into the open note and records your review. If you can't push, select More, then Copy note or Accept without pushing.

When you're done, the review shows Accepted with the date and time.

After you accept

The patient's card shows the care plan as current. To update it later, open it from the card and select Edit. Each month, aflow opens a 30-day review, and new outside results can trigger an Escalation review. Review and finalize these the same way.

To report a problem with a draft, select Give feedback below the review, or contact support@aflowhealth.com.