Diabetes Flow sheet
Patient Name: _______________________________
Date: ___________________
Weight_______ BMI________ BP_____________ P________
R ________
T ______________
Interval history______________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Home Glucose Log: _________________ ROS:
__________________________________
Last Dilated Eye Exam: _______________
Retinopathy?_________________
Last Hgb A1C/Date __________________
polyphagia
Proteinuria (date +/- or ratio)_________
__________________________________
Weight goals met
Diet compliance
ot tingling/numbness
Date ________________
Exam:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________________________
_________________________________________________________________
____________________________________________________________
Today’s Labs: Urine______ Glu_______ Ket________ Prot___________ Other:________________________________
____________________________________________________________________________________________________
Pending/checking today: AIC
CMP
Lipid panel
Spot prot/creat Other_______________________________
Assessment/plan:
Type II DM
Type I DM
Cardiovascular:
Other:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Pt. showed ability to learn, asked questions, verbalized understanding of treatment plan
Tobacco cessation counseling
Follow up___________________
Signed________________________
This form provided by Blue Cross and Blue Shield of North Carolina