Dayspring Family Health Center

Explanation for Diabetes Flow Sheet Posted to Virtual Office 5/5/03 David Bosscher, DO, FAAFP Dayspring Family Health Center

The flow sheet has 2 parts: The first page is designed to be the front of the page and is a diabetic flow sheet. The second page is designed to be the back of page 1 (our chart pages attach at the top and, therefore, we copy the 2nd page upside down on the back) and provides standards for diabetic care.

 The flow sheet is designed to include (almost) ALL information from the PECS encounter form. Our providers found it hard to flip between the flow sheet and the PECS form. Thus, (almost) all data is abstracted from the flow sheet when entering data into PECS.  We only utilize the flow sheet for planned checkup visits. It is not used during episodic visits.

Date Weight Height (initial)

Blood pressure We ask about home pressures and give credit for meeting BP goal if home pressures are in control range Goal: <130/80

Home glucoses We enter glucose ranges taken at different times during the day

HbA We circle ORDERED if done so. Our lab person enters result when it becomes available.

Foot exam (dictate if abnormal) We circle normals (printed in gray scale). We write or dictate if abnormal Dilated eye exam We note date of recommendation. We enter results of exam (N=normal or A=abnormal) when they become available. Lipid profile We circle which lipid fractions are ordered. Results are entered when they become available Goal LDL<100 (circle your orders)

LFT labs (ALT) We circle ORD when ordered. Results are entered when they become available

Micro-albumin We have stopped ordering micro-albumin when patient is on ACE or ARB. Otherwise, result entered when available

Statin use We circle Y=yes or N=no per patient data. If contraindicated, we circle CID. Or, if LDL is <100, we circle NOT indicate ASA use We circle Y=yes or N=no per patient data. If contraindicated, we circle CID. Flu-vax UTD? Per protocol. Pneumovx UTD? Per protocol (see page 2) Smoking? Same data as PECS asks for

Goal Number ? identified Corresponds to our self-management system.

Initials Provider who sees patient initials here Dayspring Family Health Center Indian Mountain Clinic Clear Fork Clinic Cumberland River Clinic

DIABETES FLOW SHEET (circle current year) 2003 2004 2005 2006 2007 2008

Name ______Male Female DOB ______Chart Number ______

Circle correct option: Type 1 Type 2 How long diabetic (yr) <5 5-10 >10

Patient History (circle and date as diagnoses become active. if date unknown): Date of Dx Date of Dx Date of Dx Coronary Artery Dx _____ 414.9 Renal complicat _____ 250.4 Alcohol abuse _____ 303.9 Hyperlipidemia _____ 272.4 Ophth complicat _____ 250.5 Tobacco abuse _____ 305.1 Hypertension _____ 404.1 DM Neuropathy _____ 250.6 ______Cerebrovascular Dx_____ 437.9 Vascular complic _____ 250.7 ______Peripheral Vasc Dx _____ 443.9 Obesity _____ 278.0 ______

Each visit Date (utilize flow Weight sheet only for Height (initial) check-up Blood pressure visits) Goal: <130/80 Home BP OK? Y N Home BP OK? Y N Home BP OK? Y N Home BP OK? Y N Home Fasting Fasting Fasting Fasting glucoses range______range______range______range______Random Random Random Random range______range______range______range______QD BID QID QD BID QID QD BID QID QD BID QID None None None None Every HbA Ordered Ordered Ordered Ordered 3-4 month Foot exam N o r m a l N o r m a l N o r m a l N o r m a l (dictate if p u l s e p u l s e p u l s e p u l s e s abnormal) Normal Normal Normal Normal sensation sensation sensation sensation No No No No lesion lesion lesion lesion Dilated Date last eval Date last eval Date last eval Date last eval eye Recommended? Y Recommended? Y Recommended? Y Recommended? Y exam N N N N

s Lipid profile Tri Tri Tri Tri TC n TC TC TC Goal g g g g o

i LDL<100 t (circle HD LD HD LD HD LD HD LD a your L L L L

u L L L L

l orders)

a LFT Ord Not Ord Not Ord Not Ord Not v indicaticated indicaticated indicaticated indicaticated

E labs (ALT) Normal Normal Normal Norma l b Abnormal Abnormal Abnormal Abnorma l a

L Micro- On ACE (Not On ACE (Not On ACE (Not indic) On ACE (Not indic) albumin indic) indic) Ord N Ord N Ord N Ord N A A A A Statin use Yes No Yes No Yes No Yes No CID CID CID CID NOT NOT NOT NOT indicated indicated indicated indicated Statin use: Statin use: ASA pressure Blood (circle or write to or write (circle med(s) New Your initialsYour management Self- med)out toDC ADD Diabetic flow revision 3-03.doc Diabetic

med.Cross Annually or more often       diabetes. 2 ConsidertherapyASA as a (MI,vascular procedure,bypass stroke TIA,PVD,or claudication,and/or angina). disease cardiovascular withestablishedpatients anyone recommendedin use >30 and all ASA Use after all means if persistently LDL>100 if all persistently means after Use Use >100 disease LDL cardiovascular when if NOW established Use LDL>200 for NOW Use GOAL Lipids: or Albuminuria (micro macro) (>120%Obesity weight);desirable indexmass body kg/m>27.3 Hypertension smokingCigarette familyhistory ofA coronary heart disease

: : Should be Prevention after is LDL<100is o o o o identified identified Number ? Goal UTD? Pneumovx UTD? Flu-vax use ASA Smoking? exercise/diet for persistent persistent LDL>130 forexercise/diet Includes Includes with diabetics Triglycerides >200Triglyceridesmg/dl lipoproteinHigh-density cholesterol in <45 and mg/dl men in<55 mg/dl women lipoproteinLow-density cholesterol Cholesterol>200mg/dl < 130/80 ( Y N Y Met al tGo Las Insulin Actos Avandiaof Glucophage Sulfonylurea Past Yes No No Yes No Yes CID Yes No primary preventionstrategy Pertinent DiabeticGuidelinesPertinent home : : w Ne l Goa blood pressure measurements are are OK) measurements blood pressure Goa Last N Y Met l Insulin Actos Avandia of Glucophage Sulfonylurea Past No Yes No Yes No Yes CID No Yes > 100 mg/dl100 w Ne l Goa in in men high-risk womenand with type1 typeor Goa Last N Y Met l Insulin Actos Avandia of Glucophage Sulfonylurea Past No Yes No Yes No Yes CID No Yes 2 in women, in kg/m>27.8 w Ne l Goa Goa Last N Y Met l Insulin Actos Avandia of Glucophage Sulfonylurea Past No Yes No Yes No Yes CID No Yes 2 in men in Goal New ACE use: Use EARLY rather than late DM Type 1, use ACE inhibitors for hypertension or microalbumin or macroalbumin DM Type 2, use ARB (ACE’s OK, too) for hypertension or microalbumin or macroalbumin (if one class is not tolerated, substitute the other class)

Microalbumin Easiest method: AM spot urine collection for albumin/creatinine ratio Detection: Normal <30 Micro-albuminuria 30 – 299 Clinical albuminuria >300

Pneumovax: Recommended for all diabetics. Re-vaccination if >65 and vaccinated >5 yr ago

Self- Goal # Goal Management: 1 Work hard to keep HbgA1C < 7 2 Exercise for 30 min ___ days per week 3 Check feet daily 4 Follow calorie controlled, low fat diet 5 Lose ___ lb before next visit 6 Take ASA every day 7 Stop smoking 8 Get yearly eye exam 9 Home glucose monitoring as recommended 10 Share feelings about my diabetes