106 1 ASSESSMENT 22 2 30 55 2 0 0 112 ASSESSMENT OF DIABETES CARE, 2010 AUDITDATE 3 5 30 29 5 2 10 112 AUDIT PERIOD ENDING DATE: FACILITYNA 3 7 30 18 7 3 20 112 FACILITY NAME: AREA 46 7 30 52 7 1 2 112 AREA: SU 57 7 30 61 7 1 2 112 SU: FACILITY 66 7 30 76 7 1 2 112 FACILITY: REGNUM 3 9 30 60 9 0 4 112 NUMBER OF ACTIVE PATIENTS IN DIABETES REGISTER: REGNUM REVIEWER 3 11 30 22 11 3 3 112 REVIEWER INITIALS: TRIBAL 3 13 30 27 13 1 3 112 TRIBAL ENROLLMENT CODE: STATE 3 15 30 23 15 3 2 112 STATE OF RESIDENCE: CHARTNUM 3 17 30 17 17 6 6 112 CHART NUMBER: DOB 3 19 30 18 19 2 10 112 DATE OF BIRTH: AGE 3 20 30 29 20 0 3 112 Calculated AGE at Review: SEX 3 22 30 8 22 0 1 112 SEX: DODX 3 25 30 40 25 2 10 112 DATE OF DIABETES DIAGNOSIS: DODX DURDM 3 26 30 19 26 0 2 112 DURATION OF DM: DMTYPE 3 28 30 28 28 0 1 112 DIABETES TYPE: DMTYPE TOBACCO 3 30 30 16 30 0 1 112 TOBACCO USE: TOBCOUNSEL 3 31 30 32 31 0 1 112 TOBAC. CESSATION COUNSELING: FEET 3 33 30 38 33 0 1 112 HEIGHT: FEET INCHES 42 33 30 49 33 102 5 112 INCHES HEIGHT 5 34 30 40 34 102 5 112 Calculated in inches: HEIGHT WEIGHT 3 36 30 31 36 0 3 112 MOST RECENT WEIGHT (LBS): BMI 5 37 30 21 37 101 4 112 Calculated BMI: HTNDXTX 3 39 30 48 39 0 1 112 HYPERTENSION (DOCUMENTED DX OR RX): HTNDXTX SYST1 3 41 30 34 41 0 3 112 LAST 3 BLOOD PRESSURES: SYST1 DIAST1 40 41 30 47 41 0 3 112 DIAST1 SYST2 28 42 30 34 42 0 3 112 SYST2 DIAST2 40 42 30 47 42 0 3 112 DIAST2 SYST3 28 43 30 34 43 0 3 112 SYST3 DIAST3 40 43 30 47 43 0 3 112 DIAST3 SYSMEAN 4 45 30 30 45 0 3 112 Calculated SYSTOLIC MEAN: DIAMEAN 39 45 30 55 45 0 3 112 DIASTOLIC MEAN: EXAMINATIO 27 48 30 39 48 0 0 112 EXAMINATIONS FOOTEXAM 3 50 30 24 50 0 1 112 FOOT EXAM, COMPLETE: EYEEXAM 3 52 30 41 52 0 1 112 EYE EXAM (DILATED OR RETINAL CAMERA): DENTALEXAM 3 54 30 16 54 0 1 112 DENTAL EXAM: EDUCATION 27 56 30 36 56 0 0 112 EDUCATION DIETINSTR 3 58 30 34 58 0 1 112 DIET INSTRUCTION IN PAST YEAR: EXERCISE 3 60 30 38 60 0 1 112 EXERCISE INSTRUCTION IN PAST YEAR: DMEDUC 3 62 30 36 62 0 1 112 OTHER DM EDUCATION IN PAST YEAR: MENTALHEAL 27 65 30 40 65 0 0 112 MENTAL HEALTH DEPDX 3 67 30 40 67 0 1 112 DEPRESSION AN ACTIVE PROBLEM: DEPDX DEPSCREEN 3 68 30 45 68 0 1 112 DEPRESSION SCREENING DURING AUDIT PERIOD: DMTHERAPY1 8 71 30 39 71 0 0 112 DM THERAPY 1=YES 2=NO TXDIET 4 73 30 36 73 0 1 112 1 DIET & EXERCISE ALONE: TXDIET TXINSUL 4 74 30 37 74 0 1 112 2 INSULIN: TXINSUL TXSUREA 4 75 30 37 75 0 1 112 3 SULFONYLUREA: TXSUREA TXSUREALK 4 76 30 39 76 0 1 112 4 SULFONYLUREA-LIKE: TXSUREALK TXMETFORM 4 77 30 39 77 0 1 112 5 METFORMIN: TXMETFORM TXACAR 4 78 30 36 78 0 1 112 6 ACARBOSE OR MIGLITOL: TXACAR TXGLIT 4 79 30 36 79 0 1 112 7 GLITAZONE: TXGLIT TXBYETTA 4 80 30 38 80 0 1 112 8 INCRETIN MIMETICS: TXBYETTA TXDPP4 4 81 30 36 81 0 1 112 9 DPP4 INHIBITORS: TXDPP4 TXAMYLIN 3 82 30 38 82 0 1 112 10 AMYLIN ANALOGUES: TXAMYLIN TXREFUNK 3 83 30 38 83 0 1 112 11 REFUSED/UNKNOWN: TXREFUNK ACE 3 86 30 26 86 0 1 112 ACE INHIBITOR/ARB USE: ASPIRIN 3 89 30 29 89 0 1 112 ASPIRIN/ANTIPLATELET USE: LIPIDLOWER 3 94 30 27 94 0 0 112 LIPID LOWERING AGENT USE LLSTATIN 3 96 30 39 96 0 1 112 1 STATIN LLSTATIN LLFIBRATE 3 97 30 40 97 0 1 112 2 FIBRATE LLFIBRATE LLNIACIN 3 98 30 39 98 0 1 112 3 NIACIN LLNIACIN LLBAS 3 99 30 36 99 0 1 112 4 BILE ACID SEQUESTRANT LLBAS LLEZETIM 3 100 30 39 100 0 1 112 5 EZETIMIBE (ZESTRA) LLEZETIM LLFISHOIL 3 101 30 40 101 0 1 112 6 FISH OIL - RX OR OTC LLFISHOIL LLLOVAZA 3 102 30 39 102 0 1 112 7 LOVAZA LLLOVAZA LLNONEREF 3 103 30 40 103 0 1 112 8 NONE OR REFUSED LLNONEREF TBTESTDONE 3 106 30 17 106 0 1 112 TB TEST DONE: TBTESTRSLT 3 108 30 31 108 0 1 112 TB TEST RESULT: TBTESTRSLT TBINHTX 3 110 30 48 110 0 1 112 IF TB TEST RESULT POSITIVE, INH TX COMPLETE: TBTESTDATE 3 111 30 43 111 2 10 112 IF TB TEST RESULT NEGATIVE, TEST DATE: TBSTATUS 3 113 30 26 113 0 1 112 Calculated TB STATUS: EKGDONE 3 117 30 22 117 0 1 112 ECG EVER: EKGDONE EKGDATE 3 118 30 31 118 2 10 112 DATE OF LAST ECG: EKGDATE IMMUNIZATI 27 121 30 40 121 0 0 112 IMMUNIZATIONS FLUVAX 3 123 30 53 123 0 1 112 SEASONAL FLU VACCINE DURING AUDIT PERIOD: FLUVAX PNEUMOVAX 3 124 30 56 124 0 1 112 PNEUMOVAX EVER: PNEUMOVAX TD 3 125 30 49 125 0 1 112 TD OR TDAP IN PAST 10 YEARS: TD LABORATORY 27 128 30 43 128 0 0 112 LABORATORY TESTS HBA1C 3 130 30 22 130 101 4 112 MOST RECENT HBA1C: HBA1CDATE 32 130 30 55 130 2 10 112 DATE DRAWN: HBA1CDATE CREATDONE 3 132 30 46 132 0 1 112 CREATININE IN PAST YEAR: CREATDONE CREATVALUE 6 133 30 47 133 101 4 112 LAST CREATININE VALUE: CREATVALUE EGFR 3 135 30 69 135 0 1 112 ESTIMATED GFR DOCUMENTED IN MED RECORD DURING AUDIT PERIOD? EGFR EGFRVALUE 3 136 30 25 136 101 5 112 ESTIMATED eGFR VALUE: CHOLDONE 3 140 30 45 140 0 1 112 TOTAL CHOLESTEROL IN PAST YEAR: CHOLDONE CHOLVALUE 6 141 30 46 141 0 3 112 LAST TOTAL CHOLESTEROL VALUE: CHOLVALUE HDLDONE 3 142 30 44 142 0 1 112 HDL CHOLESTEROL IN PAST YEAR: HDLDONE HDLVALUE 6 143 30 45 143 0 3 112 LAST HDL CHOLESTEROL VALUE: HDLVALUE LDLDONE 3 144 30 44 144 0 1 112 LDL CHOLESTEROL IN PAST YEAR: LDLDONE LDLVALUE 6 145 30 45 145 0 3 112 LAST LDL CHOLESTEROL VALUE: LDLVALUE TRIGDONE 3 146 30 45 146 0 1 112 TRIGLYCERIDE IN PAST YEAR: TRIGDONE TRIGVALUE 6 147 30 47 147 0 4 112 LAST TRIGLYCERIDE VALUE: TRIGVALUE: URINETESTE 3 149 30 27 149 0 0 112 URINE TESTED FOR PROTEIN UPTESTDONE 6 150 30 61 150 0 1 112 DURING 12 MO AUDIT PERIOD?: UPTESTDONE UPTESTTYP2 3 152 30 61 152 0 1 112 SPECIFIC TYPE OF PROTEIN TESTING DONE: UPTESTTYP2 N1ALBUMINC 6 153 30 32 153 0 0 112 1=Albumin:creatinine ratio UPACRVAL 12 154 30 59 154 101 7 112 UACR VALUE (IN MG/G): UPACRVAL N2QUANTITA 6 155 30 45 155 0 0 112 2=Quantitative protein:creatinine ratio UPPCRVAL 12 156 30 59 156 103 6 112 UPCR VALUE (IN G/G): UPPCRVAL UP24HRVAL 6 157 30 60 157 6 5 112 3=24 hr urine protein (in mg) UP24HRVAL UPMACCAT 6 158 30 59 158 0 1 112 4=Microalbumin:creatinine (e.g., Clinitek): UPMACCAT UPMACAT 6 159 30 58 159 0 1 112 5=Microalbumin only (e.g., Micral): UPMACAT UPUADIPCAT 6 160 30 61 160 0 1 112 6=Standard UA dipstick: UPUADIPCAT LOCAL 3 164 30 34 164 0 1 112 LOCAL OPTION QUESTION: LOCAL SOURCESYS 3 166 30 51 166 3 10 112 AUDIT TYPE (MANUAL VS ELECTRONIC): SOURCESYS