Diabetes Visit Note

Patient name / ID number
DOB// / Age /  M F / Height
Medication allergies/contraindications
Insurance information
Glucose Control Measures
ADA Guideline (level and testing interval) / 2008 HEDIS®a Measure / Visit 1
Date ______ / Visit 2
Date ______ / Visit 3
Date ______ / Visit 4
Date ______
A1C / A1C Goal <7%
•At goal: 2x annually
•Not at goal: quarterly / At least 1x annually
• Well controlled: <7%
• Poorly controlled:
>9% / ______%
 Well controlled
 Poorly controlled / ______%
 Well controlled
 Poorly controlled / ______%
 Well controlled
 Poorly controlled / ______%
 Well controlled
 Poorly controlled
Fasting plasma
glucose (FPG) / 90–130 mg/dL / N/A / ______mg/dL / ______mg/dL / ______mg/dL / ______mg/dL
Postprandial
plasma glucose
(PPG) / <180 mg/dL / N/A / ______mg/dL / ______mg/dL / ______mg/dL / ______mg/dL
Other Measures/Guidelines
ADA Guideline (level and testing interval) / 2008 HEDIS Measure / Visit 1 / Visit 2 / Visit 3 / Visit 4
Weight/BMI / N/A / N/A
Blood pressure / <130/80 mmHg
Measure at every
routine visit / Regular measurement
•Controlled:
<130/80 mmHg
<140/90 mmHg / ______mmHg
 Controlled
____<130/80 mmHg
____<140/90 mmHg / ______mmHg
 Controlled
____<130/80 mmHg
____<140/90 mmHg / ______mmHg
 Controlled
____<130/80 mmHg
____<140/90 mmHg / ______mmHg
 Controlled
____<130/80 mmHg
____<140/90 mmHg
Lipids
• LDL-C
• HDL-C
• Total-C
• Triglycerides / LDL-C <100 mg/dL
HDL-C >40 mg/dL (men)
>50 mg/dL (women)
Triglycerides <150
mg/dL
Not at goal: Measure
at least annually, more
frequently if needed to
reach goals
At goal: Repeat every
2 years / Testing required in
measurement year
LDL-C controlled:
<100 mg/dL / LDL-C
______mg/dL
 Controlled
HDL-C
______mg/dL
Total-C
______mg/dL
Triglycerides
______mg/dL / LDL-C
______mg/dL
 Controlled
HDL-C
______mg/dL
Total-C
______mg/dL
Triglycerides
______mg/dL / LDL-C
______mg/dL
 Controlled
HDL-C
______mg/dL
Total-C
______mg/dL
Triglycerides
______mg/dL / LDL-C
______mg/dL
 Controlled
HDL-C
______mg/dL
Total-C
______mg/dL
Triglycerides
______mg/dL
Urinary albumin/
creatinine ratio / < 30 µg/mg / Minimum annual
screening / ______µg/mg / Date ______
Flu vaccination / Annual vaccination /  Yes No /  Yes No /  Yes No /  Yes No
Pneumococcal
vaccination / At least 1 lifetime
vaccinationb /  Yes No /  Yes No /  Yes No /  Yes No
ADA = American Diabetes Association; BMI = body mass index; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; Total-C = total cholesterol.
aHealthcare Effectiveness Data and Information Set. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
bA 1-time revaccination is recommended for individuals >64 years of age who were previously immunized when they were <65 years of age if the vaccine was administered >5 years ago.
Exam and Consultation Notes
Visit 1 / Visit 2 / Visit 3 / Visit 4
Dilated eye exam
(recommended interval:
annual) /  Yes NoDate______
Notes
Foot exam (recommended interval:
each office visit) /  Yes No
Notes
/  Yes No
Notes
/  Yes No
Notes
/  Yes No
Notes
Consultation notes (includes nutrition,
exercise, etc) /  Yes No
Notes
/  Yes No
Notes
/  Yes No
Notes
/  Yes No
Notes
Educational materials
distributed and
discussed / Diabetes Management Plan
Care for Your Body Today
 Other / Diabetes Management Plan
Care for Your Body Today
 Other / Diabetes Management Plan
Care for Your Body Today
 Other / Diabetes Management Plan
Care for Your Body Today
 Other
Referral to:
Educator / Dietitian / Other
Cardiologist / Ophthalmologist
Podiatrist / Neurologist
Risk factor discussions / Heart and Blood Vessels
Date / Eyes
Date / Nervous System
Date / Kidneys
Date
Notes

Diabetes Visit Note — Medications

Patient name / ID number
DOB// / Age /  M F / Height
Medication allergies/contraindications
Insurance information
Cardiologist / Ophthalmologist
Podiatrist / Neurologist
Medications
Visit 1
Date ______ / Visit 2
Date ______ / Visit 3
Date ______ / Visit 4
Date ______
Glucose-lowering
therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy
Cholesterol-loweringtherapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy
Blood pressure therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy
Antiplatelet therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy
Other medications /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy /  No change
 Change dose/therapy
Notes

NAVIGATOR is a trademark of Merck & Co., Inc.

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