Sample Diabetes Patient Care Flow Sheet For Adults
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2Sample Diabetes Patient Care Flow Sheet For Adults
Name:
Type of diabetes:
Date of birth:
Date of Diagnosis:
Type 1 ¨ Type 2 ¨ Other ¨
Risk factors, co-morbidities
Self-management (discuss with patient add date and location in chart)
¨ Hypertension
¨ Dyslipidemia
¨ Coronary Artery Disease (CAD)
Patient Goals: _________________________________________________________________
¨ Peripheral Artery Disease
¨ Chronic Kidney Disease
Possible Barriers to Self–management: _____________________________________
¨ Mental health diagnosis
¨ Polycystic Ovarian Syndrome
Diabetes Self-management Education: _____ ______________________________
¨ Foot disease
¨ Erectile Dysfunction
¨ Weight management:
¨ Smoking ____ _______________________________________________ (Date stopped)
Ht: ______________ Target Wt: _______________ Target BMI: _______________
¨ Physical activity (aerobic 150 min/week; resistance 2-3 times/week)
¨ Alcohol: _______________________________________________ (Assess/discussed)
___________________________________________________________________________________
Vaccinations
¨ Glucose meter/lab comparison
Flu (annual)
Date: _____________________
Date: _____________________
¨ Patient Care Plan (Pregnancy Planning/ Driving License):
Pneumoccocus Date: _____________________
_____________________________________________________________ date discussed
Visits (Every 3 to 6 months)
Date
BP
Weight
A1C
Notes
Hypo-
Antihyperglycemic Agents /
Target ≤7%
glycemia
CV protection agents
(Goals, clinical status)
(ACEi / ARB / Statin / ASA as indicated*)
or _______
Review SMBG records. Target: pre-prandial 4-7 mmol/L; 2-hour post-prandial 5-10 mmol/L (5-8 mmol/L if A1C not at target)
Screen for diabetes complications annually or as indicated
Nephropathy
Neuropathy
Retinopathy
• Check feet for lesions and sensation (10-g monofilament or 128 Hz
Annual eye exam:
Date
ACR
eGFR
tuning fork)
Date: ___________________________________
• Check for pain, ED, GI symptoms
Date: ___________________________________
Date: ________________ Findings: ___________________________________________
Ophthalmologist/
Date: ________________ Findings: ___________________________________________
Optometrist:
Date: ________________ Findings: ___________________________________________
__________________________________________
*For vascular protection:
Lipids Targets: If indicated to treat LDL-C ≤2 mmol/L
CAD Assessment
¨ Statins if ≥40 yrs OR >30 yrs
ECG: ____________________________________
and >15 yrs duration OR end
Date
Medication LDL-C HDL-C
TG
(Non-HDL-C)
(Apo B)
Stress ECG: _______________ _________________
organ damage
Other: __________________________________
¨ ACEi/ARB if ≥55 yrs OR end
organ damage (even in the
absence of hypertension)
See reverse side for care objectives and targets
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