DSMES INTERVENTION TRACKING FORM

Participant Name: Participant 7 Date of Birth: 8/15/1938

7/14/2022
Learning Needs:
DSMES PLAN
WHAT TOPICS: ☐ Healthy Coping ☒Healthy Eating ☐ Being Active ☐ Taking Medication

☒Monitoring ☐ Problem Solving ☒ Reducing Risks

HOW: ☐ Group ☐ Individual (special needs: Participant learns effectively with one-on-one session. )

WHERE: ☐ In-person ☐ Telehealth ☐ Telephone (audio-only) WHEN (date of first session): 7/14/22

Session #1 Session #2 Session #3 Session #4

DATE OF SERVICE: (7/14/22)
TIME SPENT:
in 30-minute units 27 minutes

INDIVIDUAL OR individual
GROUP
TOPICS COVERED ☐Healthy Coping ☐ Healthy Coping ☐ Healthy Coping ☐ Healthy Coping
Check all thatapply ☐Healthy Eating ☐ Healthy Eating ☐ Healthy Eating ☐ Healthy Eating
☐ Being Active ☐ Being Active ☐ Being Active ☐ Being Active
☒Taking Medication ☐ Taking Medication ☐ Taking Medication ☐ Taking Medication
☒Monitoring ☐ Monitoring ☐ Monitoring ☐ Monitoring
☐ Problem Solving ☐ Problem Solving ☐ Problem Solving ☐ Problem Solving
☒Reducing Risks ☐Reducing Risks ☐ Reducing Risks ☐ Reducing Risks
Participant -send text/call reminders to
DSMES Progress the patient to take his
medications on time
and Plan:
- send text/ email of topics
related to the reduction of
risks.
-call/text patient to monitor
blood sugar and BP
Clinical or - Patient is now
Behavioral using RPM
devices to monitor
Outcome
his health
- Patient is still
missing scheduled
blood glucose
checks
DSMES Team
Signature: Bryan Mortera
Participant’s SMART goal: The patient will be able to monitor blood glucose levels at least once a day for 30 days

Date goal set:7/14/22 Date of goal follow up: 8/14/22 Goal Progress: Never Met 1 - 2 - 3 - 4 - 5 Always Met
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