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
ADCES Tool to Satisfy Standard 7 [PDF – 314 KB]:
This tool outlines the components needed for your application for Standard 7.
DSMES/T & Nutrition Therapy Management Referral Form
This is an example of a DSMES/T and medical nutrition therapy services referral form.
Sample Referral Form
This resource is a sample DSMES/T services order form.
ADCES Webinar Slides on Charting
The webinar slides describe the components to be documented in a DSMES chart and personalized plan.
Initial Comprehensive DSMES Cycle [PDF – 567 KB]:
This graphic depicts the DSMES cycle for Standards 7, 8, and 9.
Education Record [PDF – 371 KB]:
This document is a sample participant record.
Behavior Change Objectives [PDF – 62 KB]:
This resource contains examples of participant behavior goals.
Behavior and Other Participant Outcomes [PDF – 274 KB]:
This is a template for behavior and other participant outcomes.
Sample DSMES Assessment Form [DOCX – 326 KB]:
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 – 106 KB]:
This is a sample participant DSMES assessment data collection and review policy.
DSME Assessment Example 1 – English [DOC – 92 KB]:
This link will download a form for a participant’s self-assessment in English.
DSME Assessment Example 2 – Spanish [DOCX – 49 KB]:
This link will download a form for a participant’s self-assessment in Spanish.
Physician Referral Form [PDF – 24 KB]:
This is an example of a detailed physician referral form.
Short Referral Form [PDF – 68 KB]:
This is an example of a brief referral form.
Chart Review Form [PDF – 363 KB]:
This document is a sample chart review form used to ensure participant records are complete.
Chart Tracker [PDF – 209 KB]:
The is a sample form for chart tracking.
Complete Patient Chart Audits [PDF – 135 KB]:
This document shows the required number of complete participant chart audits for each multi-site.