eMERGE Supplemental Project: Diabetes & Diabetic Retinopathy

CHART REVIEW FORM - 03/24/2010

______Reviewed: Reviewer ID ______Study ID ______QA: Yes No

Date __ __ /__ __ / ______(mo/date/yr) Index date: __ __ /__ __ /______(mo/date/yr)

______

  1. Patient has at least 1 diagnosis of diabetes:
No(EXCLUDE - STOP)
YesDate of first known diagnosis ___/___/_____
Type:
Type I / Juvenile
Type II / Adult
OtherPlease specify: ______
Undetermined
Patient has at least one other diagnosis of diabetes
No(SKIP TO QUESTION 2)
Yes
Type (if different from first diagnosis):
Type I / Juvenile
Type II / Adult
OtherPlease specify: ______
Undetermined
  1. Patient has/had ketoacidosis
No/Unknown(SKIP TO QUESTION 3)
Yes Date of first known diagnosis ___/___/_____
  1. Hypertension
No/Unknown(SKIP TO QUESTION 4)
Yes Date of first known diagnosis ___/___/_____
  1. Hyperlipidemia(Includes dyslipidemia, hypercholesterolemia, or hypertriglyceridemia)
No/Unknown(SKIP TO QUESTION 5)
Yes Date of first known diagnosis ___/___/_____
  1. Family history of diabetes mellitus:
Unknown(SKIP TO QUESTION 6)
No(SKIP TO QUESTION 6)
Yes
If Yes, which relatives:
Mother Grandmother - how many:_____
Father Grandfather - how many:_____
Brother - how many: _____ Uncle - how many:_____
Sister - how many: _____ Aunt - how many:_____
Son - how many: _____ Cousin - how many:_____
Daughter - how many: _____ Other: ______how many: _____
  1. Has had an office visit in last 24 months:
No(SKIP TO QUESTION 7)
Yes Date of visit ___/___/_____
Currently using insulin?
No
Yes
Currently using a statin?
No
Yes
  1. Patient has ever been treated with insulin
No
YesDate of medication documentation ___/___/_____
  1. Patient has ever been on metformin (Glucophage):
No(SKIP TO QUESTION 9)
YesDate of first treatment ___/___/_____ Unknown (SKIP TO QUESTION 9)
Concomitant insulin:
No
YesDate of medication documentation ___/___/_____
Other concomitant medications:
No
YesDate of medication documentation ___/___/_____
  1. Patient has ever been treated with sulfonylurea:
No(SKIP TO QUESTION 10)
YesDate of first treatment ___/___/_____ Unknown (SKIP TO QUESTION 10)
Concomitant insulin:
No
YesDate of medication documentation ___/___/_____
Other concomitant medications:
No
YesDate of medication documentation ___/___/_____
  1. Patient has ever been treated with any other medication for diabetes (excluding metformin and sulfonylureas)
No(SKIP TO QUESTION 11)
YesDate of first mention ___/___/_____ Unknown (SKIP TO QUESTION 11)

Concomitant insulin:
No
YesDate of medication documentation ___/___/_____
Other concomitant medications:
No
YesDate of medication documentation ___/___/_____
  1. Patient has a confirmed diagnosis of diabetic retinopathy and/or macular edema
No(SKIP TO QUESTION 12)
Yes
List the first mention of each type of diabetic retinopathy or macular edema.
Please have a separate entry for each eye*.
Type EyeFirst Date
BackgroundLeft____/____/______
Right____/____/______
Unknown____/____/______
ExudativeLeft____/____/______
Right____/____/______
Unknown____/____/______
IschemicLeft____/____/______
Right____/____/______
Unknown____/____/______
NonproliferativeLeft____/____/______
Right____/____/______
Unknown____/____/______
ProliferativeLeft____/____/______
Right____/____/______
Unknown____/____/______
Macular edemaLeft____/____/______
Right____/____/______
Unknown____/____/______
OtherLeft____/____/______
Right____/____/______
Unknown____/____/______/ * If either or both eyes are absent, please indicate so below:
Left eye not present
Date: ____/____/______
Right eye not present
Date: ____/____/______
Quick Reference:
OD = right eye
OS = left eye
OU = both eyes
  1. Patient had a procedure performed for diabetic retinopathy or macular edema.
No(SKIP TO QUESTION 13)
Yes
List the first date the procedure was recorded ___/___/_____
  1. Patient had a dilated eye exam within the past 2 years.
No(EXCLUDE - STOP)
YesDate of most recent dilated eye exam: ___/___/_____
  1. Last eye exam has indications of diabetic retinopathy or macular edema.
No(CONTROL - STOP)
Yes
  1. Additional comments/notes

  1. Review Completed:
YesDate completed: ___/___/_____