/ Texas Workforce Commission
Vocational Rehabilitation Services

Diabetes Self-Management

Educator Notes

Instructions
  • Review previous visit.
  • Only describe education provided this visit.
  • Set behavior change and education goals for next visit.
  • As appropriate, you may use the following abbreviations: NA for “not applicable”,ND for “not disclosed by customer”, or NE for “not evaluated”.

Customer Information
Customername: / TWS-VRS Case ID:
Counselor name: / Service authorization number:
Diabetes Self-Management Education
Previous Visit
Date of previous visit:
What was the behavioral change goal from the previous visit?
Did the customer accomplish the behavioral change goal? Describe successes and barriers to change.
How did you evaluate the behavioral change goal (return demonstration, verbal feedback, etc.)?
What does the customer recall from the previous visit?
Was there anything that was difficult for the customer to implement?
**AADE7 Self-Care Taught This Visit / Describe Education Provided
Vocational Rehabilitation
Healthy Eating
Being Active
Monitoring
Taking Medications
Healthy Coping
Problem Solving
Reducing Risk
Other Diabetes Concerns
Observations and Comments
Current Blood Glucose Reading:
Premeal Postmeal
Date: Time: Result: / Educational materials provided or community resource referrals:
Nonvisual training was provided on the following:
Educational Setting: / Individual Group
Behavioral Change Goal for Next Visit
Customer will work on this behavioral change goal until our next visit:
What will education focus on next visit?
Visit date: / Start time: / End time: / Total hours:
Hours recommended for next visit:
**AADE7 Self-Care is a tool provided by the American Association of Diabetes Educators. The primary goal of diabetes education is to provide knowledge and skill training and to help identify barriers, facilitate problem-solving, and develop coping skills to achieve effective self-care management and behavior change.
Signatures
Diabetes EducatorSignature (Required for all providers)
By signing below, I, the Diabetes Educator, certify that:
  • the above dates, times, and services are accurate;
  • I personally provided all services and documented all information described on this form;
  • allOutcomes Require for Payment, as described in the TWC VR Standards for Provider and Service Authorization(s) were met;
  • I maintain the staff qualifications required for the service provided as described in the TWC VR Standards for Providers or Service Authorization.

Diabetes Educator typed name: / Diabetes Educatorsignature:
X / Date:
Director Credentials and Signature
Required for Traditional-Bilateral Contractors
By signing below, I, the Director, certify that:
  • I handwrote my signature and the date below; and
  • I ensure that the staff meets the qualifications and met the requirements in the Standards for Providers when delivering the service and;
  • I maintain the staff qualifications, including the UNTWISE credential, required for a Director, as described in Standards for Providers and/or Service Authorization.

Qualifications / Proof of Qualification / Verified by TWS-VRS
Specify UNTWISE Credential: / UNTWISE Credential Number:
if no, DARS3490-Waiver Proof Attached / Yes No N/A
Director’s typed name: / Director’s signature:
X / Date:
VRS Use Only—
Date Form Submitted by Provider:
Date Form Received by TWS-VRS Office:
The UNTWISE website verifies that the director listed above is
NOT Credentialed Credentialed as a CRP Director
  • If the Director is not credentialed, is an approved DARS 3490, Temporary Waiver of CRP Credentials, attached to the invoice?
/ Yes No N/A
  • If yes, does the DARS 3490 approve the Director for the dates the services?
/ Yes No N/A
If unable to verify the credentials, complete the following:
  • Enter the date a copy of the submitted invoice and form was returned to the CRP with written notification that CRP staff person did not meet one of the credential criteria required.
Date: .
  • Enter the date a case note was made to document the return of invoice and required form(s)
Date: .
Printed name of VRS staff member making verifications: / Date verified:
Approval of the Report
Verified that the report is accurately completed per form instructions, in the Standards for Providers, and/or the SA / Yes / No
Verified that the appropriate service(s) was provided as stated in the Standards for Providers and/or the SA / Yes / No
Verified that the form was completed in its entirety / Yes / No
Verified that this individual session was held for two hours. / Yes / No
Verified that the form was submitted to VRS within 35 days of completion. / Yes / No
Verified that if the diabetes self-management education services include providing the customer with a talking blood glucose meter or other diabetes equipment, the diabetes educator obtained the customer's signature on VRS2889 to acknowledge receipt of equipment or supplies and submitted the VRS2889. / Yes / No
Verified that the appropriate fee(s) was invoiced / Yes / No
If any question above is answered “No,” complete the following:
  • Send a copy of the submitted invoice and the report with the DARS3460 to the provider for written notification that service delivery or report did not meet the requirements as described in the Standards for Providers and/orSA Date:

  • Record a case note to document the return of invoice and required form(s)Date:

Report: Approved Sent back to provider
Comment (if any):
Printed name of VR staff member making verification: / Date Verified:

DARS2884 (10/17) Diabetes Self-Management Educator Notes Page 1 of 4