ASSESSMENT OF DIABETES CARE, 2010 {AUDIT} PERIOD ENDING {DATE}: {FACILITY NA}ME: AREA: __ SU: __ FACILITY: __ NUMBER OF ACTIVE PATIENTS IN DIABETES REGISTER: {REGNUM} #### {REVIEWER} INITIALS: {TRIBAL} ENROLLMENT CODE: ___ {STATE} OF RESIDENCE: {CHART NUM}BER: ###### {D}ATE {O}F {B}IRTH: Calculated {AGE} at Review: ### SEX: # DATE OF DIABETES DIAGNOSIS: {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}: ##.# HYPERTENSION (DOCUMENTED DX OR RX): {HTNDXTX} # LAST 3 BLOOD PRESSURES: {SYST1} ### {DIAST1} ### {SYST2} ### {DIAST2} ### {SYST3} ### {DIAST3} ### Calculated {SYS}TOLIC {MEAN}: ### {DIA}STOLIC {MEAN}: ### EXAMINATIONS {FOOT EXAM}, COMPLETE: # {EYE EXAM} (DILATED OR RETINAL CAMERA): # DENTAL EXAM: # EDUCATION {DIET INSTR}UCTION IN PAST YEAR: # {EXERCISE} INSTRUCTION IN PAST YEAR: # OTHER {DM EDUC}ATION IN PAST YEAR: # MENTAL HEALTH DEPRESSION AN ACTIVE PROBLEM: {DEPDX} # {DEP}RESSION {SCREEN}ING DURING AUDIT PERIOD: # DM THERAPY 1=YES 2=NO 1 DIET & EXERCISE ALONE: {TXDIET} # 2 INSULIN: {TXINSUL} # 3 SULFONYLUREA: {TXSUREA} # 4 SULFONYLUREA-LIKE: {TXSUREALK} # 5 METFORMIN: {TXMETFORM} # 6 ACARBOSE OR MIGLITOL: {TXACAR} # 7 GLITAZONE: {TXGLIT} # 8 INCRETIN MIMETICS: {TXBYETTA} # 9 DPP4 INHIBITORS: {TXDPP4} # 10 AMYLIN ANALOGUES: {TXAMYLIN} # 11 REFUSED/UNKNOWN: {TXREFUNK} # {ACE} INHIBITOR/ARB USE: # {ASPIRIN}/ANTIPLATELET USE: # LIPID LOWERING AGENT USE 1 STATIN {LLSTATIN} # 2 FIBRATE {LLFIBRATE} # 3 NIACIN {LLNIACIN} # 4 BILE ACID SEQUESTRANT {LLBAS} # 5 EZETIMIBE (ZESTRA) {LLEZETIM} # 6 FISH OIL - RX OR OTC {LLFISHOIL} # 7 LOVAZA {LLLOVAZA} # 8 NONE OR REFUSED {LLNONEREF} # TB TEST DONE: # TB TEST RESULT: {TBTESTRSLT} # IF {TB} TEST RESULT POSITIVE, {INH TX} COMPLETE: # IF {TB} TEST RESULT NEGATIVE, {TEST DATE}: Calculated {TB STATUS}: # ECG EVER: {EKGDONE} # DATE OF LAST ECG: {EKGDATE} IMMUNIZATIONS SEASONAL FLU VACCINE DURING AUDIT PERIOD: {FLUVAX} # PNEUMOVAX EVER: {PNEUMOVAX} # TD OR TDAP IN PAST 10 YEARS: {TD} # 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 TESTED FOR PROTEIN DURING 12 MO AUDIT PERIOD?: {UPTESTDONE} # SPECIFIC TYPE OF PROTEIN TESTING DONE: {UPTESTTYP2} # 1=Albumin:creatinine ratio UACR VALUE (IN MG/G): {UPACRVAL} #####.# 2=Quantitative protein:creatinine ratio UPCR VALUE (IN G/G): {UPPCRVAL} ##.### 3=24 hr urine protein (in mg) {UP24HRVAL} ##### 4=Microalbumin:creatinine (e.g., Clinitek): {UPMACCAT} # 5=Microalbumin only (e.g., Micral): {UPMACAT} # 6=Standard UA dipstick: {UPUADIPCAT} # LOCAL OPTION QUESTION: {LOCAL} # AUDIT TYPE (MANUAL VS ELECTRONIC): {SOURCESYS}