Diabetes Planned Visit Notebook

Contents

1. Diabetes Planned Visit Algorithm
2. Decision Support
   2.11 Decision Support BP
   2.12 Decision Support BP titration orders
   2.13 BP Protocol Flow Sheet
   2.14 BP Medications
   2.20 Decision Support Glucose
   2.30 Decision Support Microalbumin
3. Self Management Goal Sheets
4. Pre-Visit Questionnaire
5. Outpatient Dietitian Referral Form—(Not included)
6. Summa Diabetes Center Referral Form—(Not included)
7. MNT Referral—(Not included)
8. Tobacco Quit Line Referral—(Not included)
9. Smoking Cessation Community Resources Stickey
10. Tobacco Use Cessation Stickey—(Not included)
11. Bupropion SR Stickey—(Not included)
12. Therapeutic Shoes Request
13. Lab Stickey—(Not included)
14. Glucagon/OTC Stickey—(Not included)
15. Insulin syringe Stickey—(Not included)
16. Pen and Pen needle Stickey—(Not included)
17. Insulin Vials Stickey—(Not included)
18. Meters and Test Strips Stickey—(Not included)
19. Lancet's Stickey—(Not included)
20. Monofilament—(Not included)
21. ACIC Forms—(Not included)
22. Blood Sugar Diary
23. Type 2 Diabetes
24. Hypoglycemia
25. Exercise
   25.11 Safe & Healthy Exercise
   25.12 Exercise for Diabetics
26. Oral Diabetes Medications
27. Blood Glucose and Urine Ketone Testing
28. All About Insulin
29. Diabetes
   29.11 Preparing for Sick Days
   29.12 Sick Day Record
30. Alcohol and Diabetes
31. Steps to Healthy Feet
32. Eye Care and Retinopathy
33. Recognizing Stroke & TIA Symptoms
34. High Blood Pressure
35. Heart Disease Booklet—(Not included)
36. Other
   36.1 Selected Preventive Foot Care Guidelines and Resources for Providers & Patients with DM
   36.2 Your Insulin Regimen Day of Surgery
   36.3 Your Insulin Regimen
   36.4 Your Insulin Day of Surgery Mixed
   36.5 Smoking—Is This the Right Time to Quit?
   36.6 Handout—Nicotine Gum
   36.7 Handout—Nicotine Lozenge
   36.8 Handout—Nicotine Patch
   36.9 Handout—Nicotrol Inhaler
     36.91 Handout—Nicotrol NS
     36.92 Handout—NRT & Bupropion combined
     36.93 Physician checklist/instructions for starting Insulin
     36.94 Physician Pharmacologic guidelines

Page last reviewed October 2014
Internet Citation: Diabetes Planned Visit Notebook. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/diabnotebk/index.html