Robert Martinez

RPM CCM 93% Adherence
45 years old • MRN: 847293 • Last Interaction: 01/20/2025 • PCP: Dr. Michael Roberts
Care Plan
Overview
Monthly Patient Charts
Medications
Lab Results
Provider Notes
History

Active Care Goals

Blood Glucose Management
  • • Daily glucose monitoring via RPM device
  • • Weekly pharmacist consultation for medication optimization
  • • Monthly HbA1c trend analysis
Hypertension Control
  • • Twice-daily BP monitoring
  • • Medication adherence tracking
  • • Lifestyle modification counseling

Care Team

Primary Care Provider Dr. Michael Roberts
Clinical Pharmacist Dr. Sarah Johnson
Care Coordinator Jennifer Smith, RN
Last Review 01/15/2025

Demographics

Date of Birth 05/15/1978
Age 45 years
Gender Male
Primary Language English

Insurance

Primary Insurance Blue Cross Blue Shield
Member ID XYZ123456789
Group Number 98765
Coverage Type PPO

Emergency Contact

Name Lisa Martinez (Spouse)
Phone (555) 123-4567
Relationship Spouse

Primary Diagnoses

Type 2 Diabetes E11.9
Essential Hypertension I10
Hyperlipidemia E78.5
Known Allergies
Penicillin - Rash Sulfa drugs - Hives Aspirin - GI upset

RPM Chart - January 2025

Generated: 01/22/2025
28
Days Monitored
95%
Compliance Rate
142
Avg Glucose (mg/dL)
135/82
Avg BP
Summary: Patient demonstrated excellent compliance with daily monitoring. Glucose levels trending downward with new medication regimen. BP remains slightly elevated - discussed lifestyle modifications during weekly call.

CCM Chart - January 2025

Generated: 01/22/2025
45 min
Total Time
4
Interactions
Activities Performed:
  • • Medication reconciliation and adherence review
  • • Care plan adjustments based on RPM data
  • • Coordination with PCP for lab order
  • • Patient education on diet modifications

Metformin HCl

Dose: 1000mg
Frequency: Twice daily
Last Fill: 01/05/2025
Prescribed by Dr. Michael Roberts • Started: 06/15/2024

Lisinopril

Dose: 10mg
Frequency: Once daily
Last Fill: 12/28/2024
Prescribed by Dr. Michael Roberts • Started: 03/10/2024

Atorvastatin

Dose: 40mg
Frequency: Once daily at bedtime
Last Fill: 01/10/2025
Prescribed by Dr. Sarah Williams • Started: 11/20/2024
HbA1c
7.2%
01/10/2025
↑ Above target
Total Cholesterol
218 mg/dL
01/10/2025
Borderline high
eGFR
68 mL/min
01/10/2025
Normal
LDL Cholesterol
142 mg/dL
01/10/2025
↑ Above target
Dr. Michael Roberts - Internal Medicine 01/15/2025 - 2:30 PM

Patient presenting with elevated HbA1c despite medication compliance. Increasing metformin dose to 1000mg BID. Also starting atorvastatin for cholesterol management. Patient enrolled in RPM program for closer glucose monitoring. Will reassess in 3 months.

Sarah Johnson, PharmD - Clinical Pharmacy 01/10/2025 - 10:15 AM

Comprehensive medication review completed. Patient reports occasional missed evening doses of metformin due to work schedule. Discussed strategies for improving adherence including phone reminders. No drug interactions identified with current regimen.

Jennifer Smith, RN - Care Coordination 12/28/2024 - 3:45 PM

Monthly CCM call completed. Patient expressed frustration with dietary restrictions during holidays. Provided education on carb counting and healthy alternatives. Scheduled nutrition consult for next week. Patient agreeable to starting RPM program in January.

📞 Outbound Call - CCM Monthly Check-in
01/20/2025 - 2:15 PM

Duration: 22 minutes. Discussed medication adherence, reviewed recent lab results, scheduled follow-up with PCP.

💊 Pharmacy System - Prescription Filled
01/10/2025 - 11:30 AM

Atorvastatin 40mg filled. 90-day supply. Copay: $15.00

📋 Care Plan Updated
01/05/2025 - 9:00 AM

Added new goal for cholesterol management. Updated medication list with atorvastatin.

✅ Program Enrollment - RPM
01/02/2025 - 10:00 AM

Patient enrolled in Remote Patient Monitoring program. Devices shipped: Blood glucose monitor, BP cuff.

📞 Inbound Call - Patient Inquiry
12/28/2024 - 4:30 PM

Duration: 8 minutes. Patient called regarding refill status for lisinopril. Prescription sent to pharmacy.