The TSWF Metabolic CPG AIM form is intended to be used in primary care settings for documenting the care of patients diagnosed with diabetes, dyslipidemia, hypertension, and/or obesity.

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Training Material for All Users

AHLTA and other training resources

Additional TSWF support

Metabolic Recent Changes

  • 19 changes for Sep-Dec 2017 update
  • Sep-Dec r2 (updated October 2017): Verbiage change for HPV recommendations as listed:
  • Sep-Dec r2 (updated October 2017): Minor word changes to the PHQ-9 to perfectly mirror the Pfizer Inc. version

Metabolic-specific Changes:

  • HPI Tab:
    -Added “Therapeutic lifestyle changes”
    -Inserted “Consider”
    -Removed ACE Inhibitors
  • Changed Labs (ADA Recommendations)
  • Updated link to 2017 ADA Standards of Care:
  • Updated Diabetes Diagnosis and Classification table
  • Updated Glycemic Goals – Determination of Target HbA1C Level table
  • Diabetes reference tab #4: Updated ASA Therapy recommendations
  • Removed Workflow Process for DM and Concurrent Risk Factors algorithm; replaced with General Care and Treatment (Module A), and Diabetes Self-Management Education (Module B)
  • Added Sequential Treatment of Type II Diabetes table

General PCMH Form Changes:

  • Added the term FIT-DNA to the Preventive Services Recommendation for colorectal cancer screening
  • Added a link next to the diabetes CCP for a diabetic foot exam. (The tool is hosted on the website)
  • Changed order of screenings on BH/Other tab. PCL-5 now follows GAD-2
  • Added 2 contraceptive counseling links above the “Presently Using Birth Control” section
    Details: CDC Reproductive Health:
    Mobile app & eBook: eBook Reader App Recommendations for Contraceptive Use and downloaded ebook:
  • Changed “annual” to “biennial” before “Retinal Eye exam done”
  • PE Tab: Moved “Accommodation” to the right of the solid line with other exam items not routinely performed
  • Moved ”Spleen” and “Abdominal Hernia” to the right of the solid line with other exam items not routinely performed



  • Focused documentation of metabolic disorders
  • Similar to CORE form
  • Follows VA/DoD CPGs

The Metabolic CPG AIM form was created with two major objectives in mind. The first objective was to focus the documentation of care for patients with diabetes, dyslipidemia, hypertension, and/or obesity, with associated clinical decision support elements embedded in the form. Secondly, the form was designed to be very similar to the TSWF CORE form. This was done in order to minimize the learning curve, while allowing for those “oh, by the way, doc” patient concerns without having to switch AIM forms. The template is updated from time to time as new evidence emerges. VA/DoD Clinical Practice Guidelines are the main source for clinical recommendations related to the four conditions.

Form Lead

TSWF Metabolic Form Lead
Dr. James Neville, MD, MPH, FACPM

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