Standard 7 – Individualization

DSMES needs will be identified and led by the participant with assessment and support by one or more DSMES team members. Together, the participant and DSMES team member(s) will develop an individualized DSMES plan.

Tools to Satisfy Standard 7

AADE

AADE Tool to Satisfy Standard 7 pdf icon[PDF – 314 KB]external icon:
This tool outlines the components needed for your application for Standard 7.

ADA

Initial Comprehensive DSMES Cycle pdf icon[PDF – 567 KB]external icon:
This graphic depicts the DSMES cycle for Standards 7, 8, and 9.

Education Record pdf icon[PDF – 371 KB]external icon:
This document is a sample participant record.

Behavior Change Objectives pdf icon[PDF – 62 KB]external icon:
This resource contains examples of participant behavior goals.

Behavior and Other Participant Outcomes pdf icon[PDF – 274 KB]external icon:
This is a template for behavior and other participant outcomes.

Sample DSMES Assessment Form word icon[DOCX – 326 KB]external icon:
This link will download a document that can be used for participant self-assessment of diabetes management.

Sample Participant DSMES Assessment Data Collection and Review Policy pdf icon[PDF – 106 KB]external icon:
This is a sample participant DSMES assessment data collection and review policy.

DSME Assessment Example 1 – English word icon[DOC – 92 KB]external icon:
This link will download a form for a participant’s self-assessment in English.

DSME Assessment Example 2 – Spanish word icon[DOCX – 49 KB]external icon:
This link will download a form for a participant’s self-assessment in Spanish.

Physician Referral Form pdf icon[PDF – 24 KB]external icon:
This is an example of a detailed physician referral form.

Short Referral Form pdf icon[PDF – 68 KB]external icon:
This is an example of a brief referral form.

Chart Review Form pdf icon[PDF – 363 KB]external icon:
This document is a sample chart review form used to ensure participant records are complete.

Chart Tracker pdf icon[PDF – 209 KB]external icon:
The is a sample form for chart tracking.

Complete Patient Chart Audits pdf icon[PDF – 135 KB]external icon:
This document shows the required number of complete participant chart audits for each multi-site.

Page last reviewed: July 24, 2019