Key Health Metrics
Average Improvement: 8% (last 30 days)
BP Average (30 days): 122/80 mmHg
BP Average (60 days): 124/81 mmHg
BP Average (90 days): 125/82 mmHg
Conditions: Hypertension, Type 2 Diabetes
Progress Snapshots
⚠
Non-Compliant: 3 missed readings
RPM
40 min
Goal: 60 min
CCM
30 min
Goal: 40 min
BHI
15 min
Goal: 20 min
RTM
10 min
Goal: 20 min
CGM
25 min
Goal: 50 min
APCM
05 min
Goal: 10 min
Ongoing Medications
- Lisinopril (10mg)
- Metformin (500mg)
Sticky Notes
- Follow up on diet plan next week
- Patient prefers morning calls
Continuous Glucose Monitoring (CGM)
Formulas & Calculation Details:
- Average Glucose: (Sum of all glucose readings in period) / (Number of readings)
- Time in Range (TIR): (Number of readings 70-180 mg/dL / Total readings) × 100%
- Time Above Range (TAR): (Number of readings >180 mg/dL / Total readings) × 100%
- Time Below Range (TBR): (Number of readings <70 mg/dL / Total readings) × 100%
- Trend: Compare current value to previous: ↑ if rising, ↓ if falling, → if stable
Current Glucose Status
📊
Current Reading: 125 mg/dL
Trend: ↗ Rising Slowly
Last updated: 10 minutes ago
Recent Alerts
Today 2:30 PM: High glucose alert - 280 mg/dL
Yesterday 11:45 PM: Low glucose alert - 65 mg/dL
Glucose Trends
24-Hour Glucose Pattern
7-Day Average
Glucose Statistics ⓘ
| Time Period | Average (mg/dL) | Time in Range (70-180 mg/dL) |
Time Above (>180 mg/dL) |
Time Below (<70 mg/dL) |
|---|---|---|---|---|
| Last 24 Hours | 142 | 78% | 18% | 4% |
| Last 7 Days | 156 | 72% | 23% | 5% |
| Last 30 Days | 148 | 75% | 20% | 5% |
Detailed Glucose Log
| Date | Time | Glucose (mg/dL) | Trend | Notes |
|---|---|---|---|---|
| 2025-07-28 | 08:00 AM | 125 | ↗ Rising | Pre-breakfast reading |
| 2025-07-28 | 07:45 AM | 118 | → Stable | Fasting glucose |
| 2025-07-28 | 02:30 AM | 280 | ↑↑ Rising Fast | High alert triggered |
| 2025-07-27 | 11:45 PM | 65 | ↓ Falling | Low alert triggered |
| 2025-07-27 | 06:30 PM | 185 | ↗ Rising | Post-dinner spike |
| 2025-07-27 | 12:00 PM | 142 | → Stable | Post-lunch reading |
| 2025-07-27 | 08:15 AM | 98 | → Stable | Morning reading |
CGM Documentation
History of previous CGM notes
| Date | Type | Detail | Communication | Note |
|---|---|---|---|---|
| 2025-07-28 | Alert Response | Alert Follow-up | Phone Conversation – Interactive | Contacted patient regarding high glucose alert (280 mg/dL) at 2:30 AM. Patient reported late dinner and forgot medication. Reviewed proper timing for meals and medications. |
| 2025-07-26 | CGM Data Review | Time in Range Assessment | Phone Conversation – Interactive | Weekly CGM review completed. Time in range improved to 75% from 68% last week. Discussed strategies to reduce post-meal spikes. Patient reports good adherence to monitoring. |
| 2025-07-24 | Device Calibration | Pattern Analysis | Text message | CGM sensor replaced and calibrated. Sent reminder to patient about proper sensor care and when to expect next replacement. |
Device Information
| Device Model | Serial Number | Sensor Status | Battery Level | Last Sync | Next Replacement |
|---|---|---|---|---|---|
| FreeStyle Libre 3 | CGM-789123 | Active | 85% | 2 minutes ago | August 8, 2025 |
Advanced Primary Care Management (APCM)
APCM Documentation
History of previous APCM notes
| Date | Type | Detail | Communication | Note |
|---|---|---|---|---|
| 2025-06-10 | Primary Care Management | Assessment | Phone Conversation – Interactive | Initial APCM assessment completed. No major issues identified. Plan to follow up in 1 month. |
Remote Physiologic Monitoring (RPM)
Formulas & Calculation Details:
- Average Heart Rate / SpO2 / Glucose: (Sum of all values in period) / (Number of values)
- Blood Pressure Mean Arterial Pressure (MAP): (Systolic BP + 2 × Diastolic BP) / 3
- BMI: Weight (kg) / (Height (m))2
- Panic Value Highlight: If value exceeds safe thresholds (e.g., HR > 140, SpO2 < 88%, Glucose > 300 mg/dL), highlight in red
- Trend: Compare current value to previous: ↑ if rising, ↓ if falling, → if stable
Vitals
⚠️
PANIC VALUES DETECTED
6/21: HR: 140 BPM, BP: 185/110 mmHg, SpO2: 85%, Glucose: 350 mg/dL
6/19: HR: 45 BPM, SpO2: 82%, Glucose: 450 mg/dL
6/19: HR: 45 BPM, SpO2: 82%, Glucose: 450 mg/dL
Blood Pressure Summary ⓘ
| Min | Avg | Max | No. of Readings |
||||
|---|---|---|---|---|---|---|---|
| SYS | DIA | SYS | DIA | SYS | DIA | ||
| 7 Days | 110 | 62 | 123 | 70 | 165 | 97 | 7 |
| 30 Days | 110 | 62 | 120 | 69 | 165 | 97 | 14 |
Heart Rate (BPM)
Blood Pressure (mmHg)
SpO2 (%)
Blood Glucose (mg/dL)
Vitals Log
| Date | Time | Heart Rate (BPM) | Blood Pressure (mmHg) | SpO2 (%) | Blood Glucose (mg/dL) |
|---|---|---|---|---|---|
| 2025-06-25 | 08:00 AM | 72 | 120/80 | 98 | 95 |
| 2025-06-24 | 08:05 AM | 75 | 122/81 | 97 | 102 |
| 2025-06-23 | 08:10 AM | 71 | 118/79 | 99 | 88 |
| 2025-06-22 | 08:15 AM | 78 | 125/82 | 96 | 110 |
| 2025-06-21 | 08:20 AM | 140 | 185/110 | 85 | 350 |
| 2025-06-20 | 08:25 AM | 73 | 121/80 | 98 | 92 |
| 2025-06-19 | 08:30 AM | 45 | 123/81 | 82 | 450 |
RPM Documentation
History of previous RPM notes
| Date | Type | Detail | Communication | Note |
|---|---|---|---|---|
| 2025-06-26 | Remote Physiologic Monitoring (99457) | Device data Review | Phone Conversation – Interactive | Reviewed patient's blood pressure readings for the past week. Readings are stable and within the target range. Patient confirmed adherence to medication schedule. No changes to care plan needed at this time. |
| 2025-06-24 | RPM Patient Training & Device Setup (99453) | Missing Readings | Left Voicemail | Patient missed blood pressure readings for two consecutive days. Left a voicemail to remind the patient to take readings and to check if they are facing any issues with the device. |
Device Management
Details about devices assigned to the patient.
| Device Type | Device IMEI number | Status | Last Sync |
|---|---|---|---|
| Blood Pressure Cuff | BP-54321 | Active | Today at 8:30 AM |
| Glucometer | GL-98765 | Active | Today at 8:35 AM |
New Device Setup
Chronic Care Management (CCM)
Care Plan
Treatment Plan Summary: Low-sodium diet, daily exercise.
Physician Notes: Patient is responding well to treatment.
Recommended Actions: Continue monitoring BP daily.
CCM Documentation
History of previous CCM notes
| Date | Type | Detail | Communication | Note |
|---|---|---|---|---|
| 2025-06-20 | Chronic Care Management | Care Plan Review | Phone Conversation – Interactive | Reviewed and updated care plan. Patient is making progress on dietary goals. |
Remote Therapeutic Monitoring (RTM)
RTM Documentation
History of previous RTM notes
| Date | Type | Detail | Communication | Note |
|---|---|---|---|---|
| 2025-06-15 | Remote Therapeutic Monitoring (98980) | Adherence Monitoring | Phone Conversation – Interactive | Discussed medication adherence and symptom tracking. Patient reported improved compliance. |
Behavioral Health Integration (BHI)
BHI Documentation
History of previous BHI notes
| Date | Type | Detail | Communication | Note |
|---|---|---|---|---|
| 2025-06-10 | BHI (99484) | Assessment | Phone Conversation – Interactive | Completed PHQ-9 and GAD-7. Patient reports mild symptoms. Plan to follow up in 1 month. |
Appointment Scheduling
Upcoming Appointments
- Cardiology Check-up - July 10, 2025 (Confirmed)
Past Appointments
| Date | Time | Reason | Status |
|---|---|---|---|
| 2025-05-20 | 10:00 AM | Annual Check-up | Completed |
| 2025-03-15 | 02:30 PM | Follow-up | Completed |
Schedule New Appointment
Billing & Invoicing
| Invoice # | Date | Amount | Status | Actions |
|---|---|---|---|---|
| INV-1001 | 2025-06-01 | $120.00 | Paid | |
| INV-1002 | 2025-06-15 | $80.00 | Unpaid |