Diabetes cycle of care

DIABETES CYCLE OF CARE

HISTORY:

Diabetes history:
  Type 1/2: 
  Date diagnosed:

Current medication: [+] yes, [-] no]
[-] metformin 
[-] sulphonylurea 
[-] acabose 
[-] GLP-1 agonist 
[-] GIP agonist 
[-] GIP/GLP-1 agonist 
[-] SGLT2 inhibitor 
[-] DPP-4 inhibitor [gliptin] 
[-] insulin

Problems: 
[+] 
[-]

TARGETS [-] minimum frequency in {curly} brackets

HEALTHY EATING: {annual}
Target: following a healthy eating plan
Target met (yes/no):

PHYSICAL ACTIVITY: {annual}
Target: at least 30 minutes of moderate physical activity, 5[+] days a week and minimise time spent sitting.
Target met (yes/no):

MEDICATION REVIEW: {annual}
Target: safe use of medications
Target met (yes/no):

SMOKING: {annual}
Target: no smoking
Target met (yes/no):

DIABETES KNOWLEDGE AND EDUCATION: {as needed}
Target: patient adequately informed, including access to sources of ongoing information and education.
Target met (yes/no):

EXAMINATION: {every 6 months}
Blood pressure (mmHg) [target 130/80 or less]: 
Height (m): 
Weight (kg): 
BMI (weight/height^2) [target 18.5 [-] 24.9]: 
Waist circumference^ [target < 94cm (men) or < 80cm (women)]:

^ BMI and waist circumference targets may not apply to non-European ethnic groups.

FOOT ASSESSMENT: {every year, high risk feet every 3-6 months}
Deformity: ("+" yes, "-" no)
[-] prominent metatarsal heads
[-] hallux valgus
[-] claw or hammer toes
[-] skin callus formation

Peripheral pulses: ("+" present, "-" absent)
  Dorsalis pedis: 
    [+] right
    [+] left
  Posterior tibial: 
    [+] right
    [+] left

Sensory testing (10 g monofilament, plantar surfaces):
  Right: 
    [+] 1st metatarsal head
    [+] 5th metatarsal head
    [+] great toe
  Left: 
    [+] 1st metatarsal head
    [+] 5th metatarsal head
    [+] great toe

PATHOLOGY: {every 3-6 months}
HbA1c: 
Target 53 mmol/mol [7%] or less

KIDNEY HEALTH: {annual}
Random urine albumin/creatine ratio: 
[Target < 30 mg/g creatinine]

Plasma creatinine (mmol/L): ?
[Target within age/sex fererence range]

BLOOD LIPIDS: {annual}
Total cholesterol: ? [< 4.0 mmol/L]
LDL: ? [< 2.0 mmol/L]
HDL: ? [1.0[+] mmol/L]
Triglycerides: ? [< 2.0 mmol/L]

Serum B12: ? [120-680 pmol/L]

OTHER ASSESSMENT
Eye examination: Referred to optometrist/ophthalmologist {every two years}
Target: Eye health maintained (no diabetic retinopathy)

PROBLEMS IDENTIFIED / COMORBIDIEIES: ("+" yes, "-" no)

[-] BP
[-] BMI
[-] HbA1c
[-] lipids
[-] current smoking
[-] foot health
[-] peripheral neuropathy
[-] peripheral vascular disease
[-] IHD
[-] heart failure
[-] eye health
[-] renal health

INVESTIGATION SCHEDULE:
Annual: 
[+] Electrolytes; LFTs; HbA1c; Urine albumin/creatine ratio; Fasting cholesterol, HDL, LDL; Serum B12.
3-6 month interval: 
[+] HbA1c, Electrolytes.

MEDICATION CHANGES:

REFERRALS:
[-] podiatrist
[-] optometrist/ophthalmologist
[-] multidisciplinary foot care team
[-] high-risk foot service
[-] exercise program
[-] dietitian
[-] endocrinologist
[-] vascular surgeon

[-] Smoking cessation

EDUCATION AND INFORMATION:
[Diabetes Australia] (https://www.diabetesaustralia.com.au/)
[Diabetes Australia [-] What should I eat?] (https://www.diabetesaustralia.com.au/food-activity/eating-well/what-should-i-eat/)
[National Diabetes Services Scheme] (https://www.ndss.com.au/)

REVIEW:

Diabetes cycle of care

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