ASSESSMENT OF DIABETES CARE, 2009 AUDIT DATE: {FACILITY NA}ME: AREA: __ {S}ERVICE {U}NIT: __ FACILITY: __ NUMBER OF ACTIVE DM PTS IN REGISTRY: {REGNUM} ##### COMMUNITY RECEIVES {SDPI GRANT} FUNDS? # SDPI {GRANT NUM}BER: REVIEWER: {TRIBAL} AFFIL: ___ {STATE} OF RESIDENCE: {CHART NUM}BER: ###### {D}ATE {O}F {B}IRTH: Calculated {AGE} at Review: ### SEX: # DATE OF DIAGNOSIS OF DM: {DODX} {DUR}ATION OF {DM}: ## DIABETES TYPE: {DMTYPE} # {TOBACCO} USE: # {TOB}AC. CESSATION {COUNSEL}ING: # HEIGHT: {FEET} # {INCHES} ##.## Calculated in inches: {HEIGHT} ##.## MOST RECENT {WEIGHT} (LBS): ### Calculated {BMI}: ##.# {H}YPER{T}ENSIO{N} {DX}'ED OR {TX}'ED IN CHART: # LAST 3 BLOOD PRESSURES: {SYST1} ### {DIAST1} ### {SYST2} ### {DIAST2} ### {SYST3} ### {DIAST3} ### Calculated {SYS}TOLIC {MEAN}: ### {DIA}STOLIC {MEAN}: ### EXAMINATIONS FOOT EXAM: # EYE EXAM: # DENTAL EXAM: # EDUCATION {DIET INSTR}UCTION IN PAST YEAR: # {EXERCISE} INSTRUCTION IN PAST YEAR: # OTHER {DM EDUC}ATION IN PAST YEAR: # DM THERAPY 1=YES 2=NO 1 DIET CONTROL ONLY: {TXDIET} # 2 INSULIN: {TXINSUL} # 3 SULFONYLUREA: {TXSUREA} # 4 METFORMIN: {TXMETFORM} # 5 ACARBOSE: {TXACAR} # 6 GLITAZONE: {TXGLIT} # 7 INCRETIN MIMETICS: {TXBYETTA} # 8 DPP4 INHIBITORS: {TXDPP4} # 9 AMYLIN ANALOGUES: {TXAMYLIN} # 10 REFUSED/UNKNOWN: {TXREFUNK} # {ACE} INHIBITOR/ARB USE: # {ASPIRIN}/ANTIPLATELET USE: # {LIPID} LOWERING {AGENT} USE: # IMMUNIZATIONS FLU VACCINE CURRENT: {FLUVAX} # PNEUMOVAX EVER: {PNEUMOVAX} # TD IN PAST 10 YEARS: {TD} # {PPD} STATUS: # IF PPD POSITIVE, WAS INH TREATMENT COMPLETE: {INHTXCOM} # IF PPD NEGATIVE, DATE OF LAST NEGATIVE PPD: {PPDDATE} Calculated {TB STATUS}: # EKG EVER: {EKGDONE} # DATE OF MOST RECENT EKG: {EKGDATE} LABORATORY TESTS MOST RECENT {HBA1C}: ##.# DATE DRAWN: {HBA1CDATE} CREATININE IN PAST YEAR: {CREATDONE} # LAST CREATININE VALUE: {CREATVALUE} ##.# ESTIMATED GFR DOCUMENTED IN MED RECORD DURING AUDIT PERIOD? {EGFR} # ESTIMATED {eGFR VALUE}: ###.# TOTAL CHOLESTEROL IN PAST YEAR: {CHOLDONE} # LAST TOTAL CHOLESTEROL VALUE: {CHOLVALUE} ### HDL CHOLESTEROL IN PAST YEAR: {HDLDONE} # LAST HDL CHOLESTEROL VALUE: {HDLVALUE} ### LDL CHOLESTEROL IN PAST YEAR: {LDLDONE} # LAST LDL CHOLESTEROL VALUE: {LDLVALUE} ### TRIGLYCERIDE IN PAST YEAR: {TRIGDONE} # LAST TRIGLYCERIDE VALUE: {TRIGVALUE}: #### URINE PROTEIN TESTING DURING 12 MO AUDIT PERIOD?: {UPTESTDONE} # TYPE OF URINE PROTEIN TESTING: {UPTESTTYPE} # 1=Quantitative albumin:creatinine ratio UACR VALUE (IN MG/G): {UPACRQVAL} ######.# 2=Semiquantitative albumin:creatinine ratio SEMIQUANT UACR CATEGORY (1,2 OR 3) {UPACRSQCAT} # 3=Protein:creatinine ratio 4=Other quantitative urine protein test (e.g., 24 hr albumin) 5=Found to have 1+protein or greater on standard UA dipstick 6=Other non-quantitative test DOES PT HAVE DEPRESSION AS AN ACTIVE DIAGNOSIS? {DEPDX} # SCREENED FOR DEPRESSION DURING 12 MO AUDIT PERIOD? {DEPSCREEN} # LOCAL OPTION QUESTION: {LOCAL} # AUDIT TYPE (MANUAL VS ELECTRONIC): {SOURCESYS}