ACCC Diabetic Flow Sheet

Toolkit for Implementing the Chronic Care Model in an Academic Environment

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.

ACCC Diabetic Flow Sheet

Patient Name: _____________________________

Medical Record Number: _____________________

Primary Physician: __________________________

Height: ___________________________________

 Date of visit (mm/dd/yy)
Every VisitGlycemic ControlFasting glucose (70-110)
Post prandial (<140)
Review blood glucoses and check when completed           
BPTarget <130/80Record Value           
OtherScreen for TobaccoYes/No           
Q3-6 Mos.HgbA1CTarget <7Record Value           
BMITarget 19-25Record Value           
Annually or as IndicatedEyesDilated Eye ExamYes/No           
Date of Exam           
KidneysUrine Microalb/Creat.Record Value           
Renal PanelRecord Creatinine           
ACE In/ARBYes/No           
Contraindication to ACE In / ARBYes/No           
FeetComprehensive 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#           
LipidsLDL <70Record Value           
OtherScreen for pain, ED, or GI disturbanceCheck if discussed           
Annual Flu ShotNote 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 DiagramThere are two images of feet. The image on the left is of the top of a foot and has the number 2 beside it. The right image shows the bottom of a foot with the numbers 1 and 3 beside it. Each image uses red circles on different parts of the toes, sole, and heel to indicate where feet are examined.
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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Page last reviewed October 2014
Internet Citation: ACCC Diabetic Flow Sheet: Toolkit for Implementing the Chronic Care Model in an Academic Environment. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.