Docstoc

DIABETES coronary artery disease

Document Sample
DIABETES coronary artery disease Powered By Docstoc
					   DIABETES (+/- coronary artery disease)
   COLLABORATIVE FLOW SHEET/ ENCOUNTER FORM
                                                                                                                                                                          ♦ PATIENT NAME
         PAST HISTORY
                                  ALCOHOL OVERUSE                                                ARRHYTHMIA: ATRIAL FIB                 ARRHYTHMIA: OTHER
                                                                                                                                                                          ♦ HSN # (OR OTHER UNIQUE PATIENT ID)                        ♦ GENDER                 Male
                                  ARTHRITIS                                                      CANCER                                 CARDIOMYOPATHY                                                                                    Female        Undifferentiated
                                  CHF                                                            CHRONIC LUNG DIS.                      DEPRESSION                        ♦ PHONE (INCLUDE AREA CODE)                         ♦ BIRTHDATE (DD-MMM-YYYY)
                                  HYPERTENSION                                                   LIPID ABNORMALITY                      LIVER DYSFUNCTION
                                  OBESITY                                                        PERIPH. VASC. DIS.                     RENAL DYSFUNCTION
                                                                                                                                                                          CHART NUMBER                    PRACTICE NAME
                                  STROKE/TIA                                                     SUBSTANCE ABUSE                        VALVULAR HD
                                                                                                                                                                          ♦ PROVIDER NAME                                            PROVIDER ID # (MSP #)
         ♦ DIABETES                                                                 YEAR OF DX:                 TYPE 1         TYPE 2        OTHER

         ♦ CAD                                                                      ___CHRONIC ANGINA, YEAR OF DX:                                   ___MI, YEAR OF DX:                   ___CABG, DATE:                             FRAMINGHAM
                                                                                                                                                                                                                                     RISK
         ___                                                                        ___ACS/UNSTABLE ANGINA , YEAR OF DX:                             ___PCI/Stent. DATE:                                                             SCORE

    DIAGNOSTIC/ CLINICAL DATA, BY DATE                                                                                                                                                                     NEW DATA                                          √ = RECALL
    REVIEW                                                                                                       ♦ = MANDATORY                         MOST RECENT DATA
    FIELDS                                                                                                                                                                                                 DATE OF VISIT:
                                                           URGENT CARE for DM &/or CAD
                                                                                                                                                                                                               None                (enter # of urgent visits)
                                                           ER/hospitalizations since last planned visit
                                        CLINICAL STATUS




                                                                                  REVIEWED BLOOD GLUCOSE RECORDS                                                                                               REVIEWED
                                                          GLYCEMIC
                                                          CONTROL




                                                                                  ♦ A1C EVERY 3 MONTHS:                                                                                                    ENTER VALUE
                                                                                   TARGET ≤ 7.0%                                                                                                           DATE OF TEST
                                                                                  DIABETES MEDICATIONS/INSULIN
                                                                                                                                                                                                               REVIEWED                   ADJUSTED
                                                                                  Review & adjust PRN
                                                                                  SYMPTOMS STABLE: angina, palpitations,                                                                                      N/A         STABLE                 NOT STABLE
                                                             CAD




                                                                                  shortness of breath, swelling, dizziness                                                                                    angina      palp.  SOB              swelling dizzy
                                                           ♦ BLOOD PRESSURE                                                                                                                                ENTER VALUE
                                        HTN




                                                            TARGET ≤130/80                                                                                                                                 DATE OF TEST
     3 TO 6 MONTHS




                                                           TARGET BODY MASS INDEX (BMI)
                                                                                                                                                                                                                                     LBS           KG
                                                           18.5 – 24.9 Height: Enter weight (LBS or KG)
                                        LIFESTYLE




                                                                                                                                                                                                                                nd
                                                           ♦ SMOKING                                                                                                                                           Current         2     Hand          Past       Never
                                                           AEROBIC EXERCISE
                                                                                                                                                                                                               YES             NO                                     IA
                                                           > 30 minutes most days, moderate intensity
                                                           OTHER LIFESTYLE FACTORS
                                                                                                                                                                                                               REVIEWED
                                                           Stress, diet, alcohol
                                                                                                                                                                                                               YES
                                                          ♦ ANTI-PLATELET (ASA/OTHER)
                                                                                                                                                                                                               NO:       CI        NT       $      RF       DA       IA
                                                                                                                                                                                                               YES
                                                          ♦ ACE OR ARB
                                        MEDICATIONS




                                                                                                                                                                                                               NO:       CI        NT       $      RF       DA       IA
                                                                                                                                                                                                               YES
                                                          ♦ STATIN
                                                                                                                                                                                                               NO:       CI        NT       $      RF       DA       IA
                                                                                                                                                                                                               YES
                                                          ♦ BETA-BLOCKER (IF CAD)
                                                                                                                                                                                                               NO:       CI        NT       $      RF       DA       IA

                                                          GENERAL REVIEW & ADJUST PRN                                                                                                                          REVIEWED                   ADJUSTED

                                                                                  LDL                                                                                                                      ENTER VALUE
                                                          Fasting lipid profile
  3-6 mos (CAD)




                                                                                  Target < 2.5 mmol/L                                                                                                      DATE OF TEST
                                                           (High-risk targets)
   Annually OR

                                        DYSLIPIDEMIA




                                                                                                                                                                                                           ENTER VALUE
                                                                                  ♦RATIO                      TOTAL CHOL
                                                                                                                                                                                                           DATE OF TEST
                                                                                  (TOTAL CHOL/HDL)
                                                                                  TARGET RATIO < 4.0                                                                                                       ENTER VALUE
                                                                                                              HDL
                                                                                                                                                                                                           DATE OF TEST
                                                                                  LIPID RISK                                                                                                                   MODERATE                         HIGH

                                                           METER/LAB COMPARISON
                                        FBG




                                                                                                                                                                                                               COMPLETED
                                                           (Optimally, this is based on fasting glucose)
     ANNUALLY AND/OR OTHERWISE NOTED




                                                           DILATED EYE EXAM                                                                                                                                DATE                             IA
                                        EYE




                                                           Ophthalmologist, optometrist, retinal photo                                                                                                       OPHTHALM     OPTOM   RETIN PHOTO
                                                                                    ♦ MICROALBUMIN SCREEN                                                                                                  ENTER              NEG
                                                          Screen for




                                                                                                                                                                                                                        OR                  IA
                                                           Nephro-
                                        RENAL




                                                                                    (<2.0 M: <2.8 F) (Albumin:creatinine                                                                                   VALUE              POS
                                                            pathy




                                                                                    KIDNEY FUNCTION estimated CrCl                                                                                         SERUM CREATININE     μmol/L
                                                                                    mL/min (Cockroft-Gault formula)                                                                                        DATE OF TEST
                                                           LOWER EXTREMITY EXAM
                                                                                                                                                                                                               REVIEWED              IA
                                       NEURO-
                                       PATHY




                                                           Check for peripheral anesthesia
                                                           HISTORY AND PHYSICAL: Check for pain,
                                                                                                                                                                                                               REVIEWED
                                                           erectile dysfunction, gastrointestinal disturbance
                                                           ASSESS & DISCUSS SELF-MANAGEMENT                                                                                                                    REVIEWED
                                                           GOALS
                                                          ANNUAL INFLUENZA VACCINE                                                                                                                             COMPLETED DATE                                         CI
                                        OTHER




                                                          PNEUMOCOCCAL VACCINE                                                                                                                                 COMPLETED DATE                                         CI
                                                          ♦ REFERRAL TO DIABETES EDUCATION,                                                                                                                    YES
                                                          CARDIAC REHAB, OR OTHER                                                                                                                              NO:     NP          TRP      $       RF        DA       IA
                                                                                     CI – contraindicated NT – not tolerated $ – financial barrier RF – patient refused NP – no program available IA – Inappropriate DA – Didn’t Ask TRP– transportation barrier
Adapted from BCMA Collaborative Flowsheet                                                                                                                                                           FOR COMMENTS SEE NEXT PAGE                                Nov 8/06
DIABETES (+/- coronary artery disease)
COLLABORATIVE FLOW SHEET/ ENCOUNTER FORM
  ♦ PATIENT NAME

  ♦ HSN # (OR OTHER UNIQUE PATIENT ID)           ♦ GENDER           Male
                                                    Female   Undifferentiated

  ♦ PHONE (INCLUDE AREA CODE)               ♦ BIRTHDATE (DD-MMM-YYYY)


  CHART NUMBER                   PRACTICE NAME

  ♦ PROVIDER NAME                                PROVIDER ID # (MSP #)




  COMMENTS




Adapted from BCMA Collaborative Flowsheet                                       Nov 8/06

				
DOCUMENT INFO