Toolkit for Implementing the Chronic Care Model in an Academic Environment

Diabetes Report Card

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.

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)
__Urine microalbumin
__LDL (fasting)
__24 hour urine for creatine clearance or protein
__HDL (fasting)
__Liver provile

Cancer screening recommendations:

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

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Page last reviewed October 2014
Page originally created January 2008
Internet Citation: Diabetes Report Card. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.