Diabetes Clinic Computer Forms
All the data on diabetic patients are held on a database,
and clinic letters are generated from the database. This should mean a minimum
of data entry and dictation by yourself.
Visits are either initial (first contact), review or annual
review. The annual review obviously should be done once a year – usually a year
after the initial visit, or if an annual review has not been done in the last
12 months.
Interim Review Form
I suggest you start by looking at the last clinic visit letter,
which should show the current problem list, treatment for diabetes and drugs
for other conditions, as well as many other details about the patient.
- Attach
a patient label – if the address has changed, be sure to point this out on
your tape to the secretary
- Enter
today’s blood pressure, height should already have been entered (see last
visit letter) and weight in kilograms and urine test result (if done)
- Problems
– this is simply a free text entry – indicate any changes e.g.
patient may have developed angina. The type of diabetes should always be
included in the problem list i.e. type 1, type 2 diet alone, type 2 on
tablets, type 2 on insulin, IGT, gestational diabetes
- Clinic
comment – all you would usually write in the notes
- Drugs
– mark up if any drugs are for angina, cardiac failure hypertension or
lipids, and then note any changes (additions, inactive, dose changes) from
last visit. Do not rewrite the whole list!
- Diabetes
Treatment Details – as above update treatment types and doses
- Write
down any relevant recent blood or urine tests
- Dictate
a letter – you do not need to dictate the problem list drug lists
etc. Keep the letter short and to the point, and indicate any tests
you have requested and follow up
required.
- Referrals
– you can generate referrals to eye screening, DNS, dietitian, podiatrist
and “other” from within the database. The letters usually contain all the
information for the eye screening department, DNS, dietitian and
podiatrist, apart from your short message. For referral to “other” e.g.
vascular surgeon it is a good idea to print an extra copy of the clinic
letter
Annual Review and Initial Forms
This form is much more extensive – at an initial visit do
not fill in every box, if it means you do not have time to deal with the
current issues – the patient will come back and you can complete the details at
the next annual review. If you are using the form for an annual review look at
the last letter or last annual review – again you only need to change most information
rather than re enter the whole lot!
The first page is self explanatory.
- Problems
- this is simply a free text entry – indicate any health problems, e.g.
Type 2 diabetes, hypertension, dyslipidaemia, previous breast cancer. The
type of diabetes should always be included in the problem list i.e. type
1, type 2 diet alone, type 2 on tablets, type 2 on insulin, IGT,
gestational diabetes
- Episode
comment – simply enter the text you would usually write in the notes
- PMH
– anything important
- FH
of diabetes – any first degree relatives or more distant relatives with
any type of diabetes
- FH
of Vascular Disease – any first degree or more distant relatives with
premature vascular disease (MI, angina, CVA)
- Main
clinic details – page 3 is mainly self explanatory. Please try to ensure
patient’s height is recorded at the initial visit.
- Non
diabetic drugs – list all drugs, inhalers, drops, injections for all
conditions apart from diabetes. If this is an annual visit you should only
have to note any changes from the last visit.
- Diabetes
Drugs – record names and doses and for insulin the cartridge or vial size and
syringe type used
- Foot-care
details – list number of admissions for foot problems, if patient attends
for chiropody, how often and where? Does patient have symptoms of claudication,
ever had a vascular intervention (eg angioplasty) or have any symptoms
suggestive of neuropathy. Has the patient ever had an amputation of any
sort and if so what type (eg a toe only, above knee). “Reaction to
pinprick” should read – able to feel 10 g monofilament, pulses absent
means absent by palpation and Doppler, vibration should be with the 128 Hz
tuning fork
- Ophthalmic
details – does patient attend an ophthalmology department for regular
review? Where? Worthing Hospital, Chichester, Brighton or other. What was
the date of last review. What was the recorded visual acuity in each eye
(in Worthing Hospital notes look at the black headed sheets in notes).
What was the most severe level of retinopathy that has EVER been recorded
in each eye?
- Renal
details. Self apparent
- General
health – mostly self apparent
- For
insulin treated patients – self apparent
- Sign
the form
- Dictate
your letter and do any referrals as for interim vist
Setting targets
At the annual review you should set targets with the patient
for:
- Diabetic
control – usually aim for HBA1c < 7.5% for insulin treated and <
7.0% for tablet treated, but remember to be realistic!
- Blood
pressure – usually aim for 140/80, but again be realistic. The patient
should be taking an ACEI unless contraindicated or not tolerated, and
should also be taking aspirin
- Cholesterol
– usually aim for < 5.0
- Weight
– for those obese (BMI>30) 5 – 10% weight reduction over a year
- Smoking
– stop!
- Exercise
– do it!
There are forms with targets information available from the
receptionist.
|
