Toolkit for Implementing the Chronic Care Model in an Academic Environment

ACCC Diabetic Flow Sheet

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)
  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 There 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
Page originally created January 2008
Internet Citation: ACCC Diabetic Flow Sheet. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.