ACCC Diabetic Flow Sheet

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Each of the four pilot sites adapted the basic concepts underlying the planned visit approach to meet the unique needs of the team and patient population. The University of Cincinnati Academic Health Center's Hoxworth Internal Medicine-Pediatrics flow sheet was the biggest change to the practice.

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ACCC Diabetic Flow Sheet

Patient Name:   _____________________________

Medical Record Number: _____________________

Primary Physician: __________________________

Height: ___________________________________

				Date of visit (mm/dd/yy)
		Guidelines	Procedure
Every Visit	Glycemic Control	Fasting glucose (70-110) Post prandial (<140)	Review blood glucoses and check when completed
	BP	Target <130/80	Record Value
	Other	Screen for Tobacco	Yes/No
Q3-6 Mos.	HgbA1C	Target <7	Record Value
	BMI	Target 19-25	Record Value
Annually or as Indicated	Eyes	Dilated Eye Exam	Yes/No
			Date of Exam
	Kidneys	Urine Microalb/Creat.	Record Value
		Renal Panel	Record Creatinine
		ACE In/ARB	Yes/No
		Contraindication to ACE In / ARB	Yes/No
	Feet	Comprehensive Exam At risk patients need exam at each visit	Abnl visual? Y/N
			Abnl vasc? Y/N
			Deformity? Y/N
			Onychomyc. or Tinea Pedis Y/N
			Abnl Monofil R#
			Abnl Monofil L#
	Lipids	LDL <70	Record Value
	Other	Screen for pain, ED, or GI disturbance	Check if discussed
		Annual Flu Shot	Note Date
Self Management Sheet Reviewed with Patient Complete at every visit
Provider Initials

 

Pneumococcal vaccine      Date:
Aspirin Use [ ] Yes [ ] No (If there is a contraindication please specify __________________ )
Comprehensive Foot Exam Monofilament Sensation Diagram
Document on above chart by zone (1, 2, 3) and laterality
Please Note: The monofilament exam must be updated at least every year as part of the comprehensive foot exam (see above).

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