ASSESSMENT OF DIABETES CARE, 2005 AUDIT DATE: FACILITY NAME: AREA: __ {S}ERVICE {U}NIT: __ FACILITY: __ NUMBER OF ACTIVE DM PTS IN REGISTRY: {REGNUM} ##### COMMUNITY RECEIVES {SDPI GRANT} FUNDS? # SDPI {GRANT NUM}BER: {TRIBAL} AFFIL: ___ {COMM}UNITY: _______ REVIEWER: CHART NUMBER: {CHARTNUM} ###### DATE OF BIRTH: {DOB} Calculated AGE at Review: {AGE} ### SEX: # DATE OF DIAGNOSIS OF DM: {DODX} DURATION OF DM: {DURDM} ## DIABETES TYPE: {DMTYPE} # TOBACCO USE: {TOBACCO} # TOBAC. CESSATION COUNSELING: {COUNSEL} # HEIGHT: {FEET} # {INCHES} ##.## Calculated in inches: {HEIGHT} ##.## MOST RECENT WEIGHT (LBS): {WEIGHT} ### Calculated BMI: {BMI} ##.# HYPERTENSION DX'ED OR TX'ED IN CHART: {CHARTHTN} # LAST 3 BLOOD PRESSURES: {SYST1} ### {DIAST1} ### {SYST2} ### {DIAST2} ### {SYST3} ### {DIAST3} ### Calculated SYSTOLIC MEAN: {SYSMEAN} ### DIASTOLIC MEAN: {DIAMEAN} ### EXAMINATIONS FOOT EXAM: {FOOTEXAM} # EYE EXAM: {EYEEXAM} # DENTAL EXAM: {DENTALEXAM} # EDUCATION DIET INSTRUCTION IN PAST YEAR: {DIETINSTR} # EXERCISE INSTRUCTION IN PAST YEAR: {EXERCISE} # OTHER DM EDUCATION IN PAST YEAR: {DMEDUC} # THERAPY THERAPY: {TXCODE} #### {TXNAME}: ACE INHIBITOR/ARB USE: {ACE} # ASPIRIN/ANTIPLATELET USE: {ASPIRIN} # LIPID LOWERING AGENT USE: {LIPIDAGENT} # IMMUNIZATIONS FLU VACCINE CURRENT: {FLU VAX} # PNEUMOVAX EVER: {PNEUMOVAX} # TD IN PAST 10 YEARS: {TD} # PPD STATUS: {PPD} # IF PPD POSITIVE, WAS INH TREATMENT COMPLETE: {INHTXCOM} # IF PPD NEGATIVE, DATE OF LAST NEGATIVE PPD: {PPDDATE} Calculated: TB STATUS: {TBSTATUS} # EKG EVER: {EKG} # DATE OF MOST RECENT EKG: {EKGDATE} LABORATORY TESTS MOST RECENT HbA1c: {HBA1C} ##.# DATE: {A1CDATE} NEXT MOST RECENT HbA1c: {HBA1C2} ##.# CREATININE IN PAST YEAR: {CREATIN} # LAST CREATININE VALUE: {CREATVALUE} ##.# 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}: #### URINALYSIS OR A/C RATIO IN PAST YEAR: {UA} # PROTEINURIA PRESENT: {PROTEINURI} # MICROALBUMINURIA PRESENT: {MICROALB} # MONITORING SELF BLOOD GLUCOSE MONITORING DOCUMENTED: {SMBG} # SUPPLEMENTAL SECTION DOES PT HAVE DEPRESSION AS AN ACTIVE DIAGNOSIS? {DEPDX} # IF NOT, HAS PT BEEN SCREENED FOR DEPRESSION IN PAST YEAR? {DEPSCREEN} # LOCAL OPTION SECTION ATTENDED EPIC: {EPIC} # SESSION W FAMILY THERAPIST: {FAMTHER} # ATTENDED OTHER DIABETES SELF-MANAGEMENT EDUCATION: DIABETES AND HTN CLASS: {DMHTN} # LOWERING LIPIDS CLASS: {LOWLIPID} # MEDICAL NUTRITION THERAPY - RD: {MNT} # WEIGHT MANAGEMENT SESSION: {WTMANAG} # MCN ANNUAL CARE ATTENDED YEARLY CLINIC: {YRLYCLINIC} # FOLLOWUP YEARLY CLINIC: {FOLLOWUP} # MCN ROUTINE CARE HBA1C AVAILABLE AT PT ENCOUNTER: {A1CAVAIL} # COMPUTERIZED SBGM REPORT AVAILABLE: {SBGMREPORT} # FOOT CARE FOOT RISK STAGE PER THIS YR'S EXAM: {FOOTSTAGE} # IF STAGE 2 OR MORE, SHOE REFERRAL IN CHART: {SHOEREF} # PT SATISFIED WITH SHOES: {SHOESATIS} # SMOKING CESSATION CLASS: {SMOKECESS} #