Appendix 2

Sample Diabetes Patient Care Flow Sheet for Adults

Part A:

Name: Type of diabetes:
Type 1 ▢ Type 2 ▢ Other ▢
Date of birth: Date of diagnosis:
Risk factors, co-morbidities Self-Management (discuss with patient; add date and location in chart)
▢ Hypertension   ▢ Dyslipidemia
▢ Coronary Artery Disease
▢ Peripheral Artery Disease
▢ Chronic Kidney Disease
▢ Mental health diagnosis
▢ Polycystic Ovary Syndrome
▢ Foot disease   ▢ Erectile Dysfunction
▢ Smoking ______________________ (Date stopped)
▢ Alcohol: _______________________ (Assess/discussed)
Patient Goals: __________________________________
Possible Barriers to Self-Management: __________________________________
Diabetes Self-Management Education: __________________________________
▢ Weight Management:
Ht: ______________
Target Wt: ______________
Target BMI: ______________
▢ Physical Activity (aerobic 150 min/week; resistance 2-3 times/week)
__________________________________
▢ Glucose Meter/lab comparison
▢ Patient Care Plan (Pregnancy Planning/Driving License):
__________________________________ Date discussed
Vaccinations
Flu (annual)     Date: _____________________    Date: _____________________
Pneumoccocus    Date: _____________________
Visits (Every 3 to 6 months)
Date BP Weight A1C
Target ≤7%
or _______
Notes
(Goals, clinical status)
Hypo-
glycemia
Antihyper-
glycemic Agents /
CV protection agents

(ACEi / ARB / Statin / ASA as indicated*)
             
             
             
             
             
             
Review SMBG records. Target: pre-prandial 4-7 mmol/L; 2-hour post-prandial 5-10 mmol/L (5-8 mmol/L if A1C not at target)
Screen for diabetes complications annually or as indicated
Nephropathy Neuropathy Retinopathy
Date

_______

_______

_______
ACR

_______

_______

_______
eGFR

_______

_______

_______
• Check feet for lesions and sensation (10-g monofilament or 128 Hz tuning fork)
• Check for pain, ED, GI symptoms

Date: ___________
Findings: _________________________
Date: ___________
Findings: _________________________
Date: ___________
Findings: _________________________
Annual eye exam:
Date: __________
Date: __________

Ophthalmologist/
Optometrist:
_______________
_______________
_______________
*For vascular protection: Lipids Targets: If indicated to treat LDL-C ≤2 mmol/L CAD Assessment
▢ Statins if ≥40 yrs OR >30 yrs and >15 yrs duration OR end organ damage
▢ ACEi/ARB if ≥55 yrs OR end organ damage (even in the absence of hypertension)
Date Med LDL-C HDL-C TG (non HDL-C) (Apo B) ECG:
___________
___________
Stress ECG:
___________
___________
Other:
___________
___________
See reverse side for care objectives and targets

Part B:

Care Objective Target
Self-monitoring of Blood Glucose Ensure patient can use glucose meter, interpret results and modify treatment as needed. Develop a blood glucose monitoring schedule with patient and review records. Premeal (mmol/L) = 4.0-7.0 mmol/L for most patients 2hr Postmeal (mmol/L) = 5.0-10.0 mmol/L for most patients 5.0-8.0 mmol/L if not achieving A1C target
Blood Glucose Control Measure A1C every three months for most adults. Consider testing at least every 6 months in adults during periods of treatment and lifestyle stability when glycemic targets have been consistently achieved. A1C ≤7.0% for most patients. Individualized based on life expectancy, functional dependency, extensive coronary artery disease at high risk of ischemia, multiple comorbidities, recurrent severe hypoglycemia, hypoglycemia unawareness, longstanding diabetes unable to achieve A1C ≤7% despite best efforts (including intensified insulin).
Hypoglycemia Enquire about hypoglycemia at each visit. Discuss recognition and treatment of hypoglycemia and risk/ benefit of hypoglycemia and pharmacologic management. Avoidance of hypoglycemia especially in the elderly, those with hypoglycemia unawareness, and those with criteria for less stringent control.
Blood glucose meter accuracy Meter results should be compared with laboratory measurements at least annually, and when indicators of glycemic control do not match meter. Simultaneous fasting glucose/meter lab comparison within 20%.
Hypertension Measure BP at diagnosis and at every diabetes clinic visit <130/80
Waist Circumference Measure as an indicator of abdominal fat Central obesity defined as: WC M ≥102cm W ≥88cm (North America) WC M ≥94cm W ≥80cm (Europids; Middle-Eastern; Sub-Saharan African; Mediterranean) WC M ≥90cm W ≥80cm (Asians; Japanese; South and Central Americans)
Body Mass Index Calculate BMI (mass in kilograms/height in metres2) Healthy body weight target: BMI: 18.5-24.9
Nutrition Encourage nutritional therapy (by a registered dietitian) as an integral part of treatment and self-management. Meet nutritional needs by following Eating Well with Canada’s Food Guide
Physical Activity Discuss and encourage aerobic and resistance exercise. Evaluate those with possible CAD or microvascular complications undertaking exercise substantially more vigorous than brisk walking. Aerobic: ≥150 minutes/week Resistance: 3 sessions/week
Smoking Encourage patient to stop at each visit; provide support as needed. Smoking cessation
Chronic Kidney Disease (CKD) Identification of CKD requires screening for proteinuria using random urine ACR (2 out of 3 samples over 3 mths) and assessment of renal function using a serum creatinine converted to eGFR. Type 1 diabetes-Screen at 5 years duration and then annually if no CKD. Type 2 diabetes-Screen at diagnosis and then yearly if no CKD. Normal ACR <2.0 mg/mmol Normal eGFR >60 mL/min
Retinopathy Type 1 diabetes-Screen 5 years after diagnosis, then rescreen annually Type 2 diabetes-Screen at diagnosis and 1-2 years after initial screening if no retinopathy is present. The interval for follow-up assessment should be tailored to the severity of the retinopathy. Screening should be conducted by an experienced eye care professional. Early detection and treatment
Neuropathy/Foot Examination Type 1 diabetes-Screen 5 years duration and annually Type 2 diabetes-Screen at diagnosis, then annually Screen for neuropathy with 10-g monofilament or 128 Hz tuning fork at dorsum of great toe. In foot exam look for: structural abnormalities, neuropathy, vascular disease, ulceration, infection. Early detection and treatment. If neuropathy present: require foot care education, specialized footwear, smoking cessation. If ulcer present: manage by multidisciplinary team with expertise
Coronary Artery Disease (CAD) Conduct CAD risk assessment periodically: CV history, lifestyle, duration of DM, sexual function, abdominal obesity, lipid profile, BP, reduced pulses, bruits, glycemic control, retinopathy, eGFR, ACR. Baseline ECG and every 2 years if >40 years, >30 years and duration >15 years, end organ damage, cardiac risk factors. Vascular Protection: First priority in prevention of diabetes complications is reduction of cardiovascular risk by vascular protection through a comprehensive multifaceted approach All people with DM: optimize: BP, glycemic control and lifestyle Statin if: age ≥40 years OR macrovascular disease OR microvascular disease OR long duration of DM (DM >15 years and age >30 years)
ACEi or ARB if: age ≥55 years OR macrovascular disease OR microvascular disease
Dyslipidemia Fasting lipid levels (TC, HDL, TG and calculated LDL) at diagnosis, then yearly if treatment not initiated. More frequent testing if treatment initiated. Lipid targets for those who need therapy: Primary target: LDL ≤2.0 mmol/L or ≥50% reduction Alternate Primary target: apo B ≤0.8 g/L or non-HDL-C ≤2.6 mmol/L
Care Objectives: People with diabetes will have better outcomes if primary care providers 1) identify patients with diabetes in their practices 2) encourage self-management and use interdisciplinary team approach to attain care objectives 3) schedule diabetes-focused visits 4) use diabetes patient care flow sheets and systematic recall.

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