Diabetes Report Card

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Summa Health System Internal Medicine residents use the Diabetes Report Card to update patients on their progress. The report card pulls patient data (e.g., blood pressure, LDL, HbA1c) from a registry and presents them in an easily accessible format. It includes information about the meaning and importance of each quality measure, lists previous self-management goals set by the patient, and provides an area for new goals.

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Your Diabetes Report Card

Patient's Name: ________________________________________________________________

Address: _____________________________________________________________________

E-mail: _______________________________________________________________________

	Value	Date	Goal	Benefits
Systolic BP: (high number)	0		Under 130	Reducing BP by 10 mmHg decreases heart attack by 11%. BP less than 130/70 cuts death rates in half
Diastolic BP: (low number)	0		Under 70
LDL cholesterol			Under 100	LDL < 100 cuts death rates in half.
HgbA1C:	0.0		Under 7	A 1 point decrease reduces kidney and eye damage 30% and heart attacks by 14%.
Microalbumin:	0.0		Under 30	Treating early kidney damage postpones kidney failure and dialysis.
Weight:	0.0		Lose 5-10%	Losing 5% of body weight lowers blood pressure, blood sugar, and cholesterol.
Personal foot care			Daily	Checking daily is the best way to avoid serious infections and amputations.
Monofilament exam			Yearly
Eye doctor exam			Yearly	Detecting early eye damage preserves vision.
Pneumovax shot			2 x every 5 yrs	Immunizations prevent hospitalization and death from pneumonia.
Flu shot			Yearly
Pap Test			Yearly	Women with diabetes have an increased chance of getting breast cancer.
Mammogram			Yearly
PSA			Yearly	Early detection improves the chance for cure.
Stool (Hemoccult)			Yearly	People with diabetes have an increased chance of getting cancer of the colon and rectum.
Sigmoidoscopy/Colonoscopy			Every 5-10 yrs
Currently smoking?			Set a quit date this month	Stopping tobacco use and avoiding tobacco smoke reduces your risk of heart attack, stroke, and several cancers.

Previous Goals:

New Self Management Goals:

Things to do to stay healthy:

Lab Tests to be completed by ________________(Date)

__Lipid Profile (fasting)
__HgbA1c
__Urine microalbumin
__LDL (fasting)
__ALT/AST
__24 hour urine for creatine clearance or protein
__HDL (fasting)
__Liver provile
__BMP
__CBC

Cancer screening recommendations:

__Schedule visit with eye doctor
__Stool (Hemoccult) test
__Schedule Pap test
__PSA
__Schedule sigmoidoscopy or colonoscopy
__Schedule Mammogram

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