Nursing homes chart BB SS 1204
DIABETES SCREENING FOR HOUSEBOUND; RESIDENTIAL AND
NURSING HOME PATIENTS
Date:
Nurse:
Name:
Address:
Weight
GP
Height
Surgery address
BMI (computer will calculate)
Urinalysis
Result
MSU sent Yes / No
Protein
Sugar
Ketones
Other
EMU for Microalbumin sent [if no protein in
specimen] Yes/No
MONTITORING
BP (aim 130/85 or below):
Self/Carer
If raised, check in 1 week, report to GP
Urine testing. Y/N
Hypoglycaemia:
Episodes:
Blood sugar monitoring Y/N
Name of meter.
Hyperglycaemia
Episodes:
Quality control done Y/N
Technique checked Y/N
6monthly +/HbA1c
eGFR
BLOODS (tick which have been done)
Annually
Lipids (if indicated)
C/Es
FBC
LFT’s
TSH [if indicated]
Medication (please tick)
Check with computer print out
Check taking correct doses
Check supplies if appropriate
INSULIN
Tick if checked
Comments
Device
Injection site
Technique
Dosage
Storage
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Nursing homes chart BB SS 1204
EYES
Corrected Visual Acuity
Right
Left
Date of last optician check:
Date of last digital phtotograph:
FEET
Visual check (give details colour, temp, abnormalities)
Palpate pulses: Dorsalis Pedis
Right
Left
Comments
Palpate pulses: Posterior tibial
Right
Left
Comments
Check Sensation (monofilament see diagram)
Right
Left
Comments
Attends podiatry
Yes
No
Comments
Check footwear
Yes
No
Comments
DIET
Discuss and comment [clinician to have up to date knowledge on diet].
Patient has good understanding / Has basic understanding / Has little understanding / Needs advice &
referral
Flu jab given yes / no
Batch no. / expiry date
Date given:
Pneumonia jab given yes / no
Batch no./ expiry date
Date given:
Smoker
Alcohol:
Yes/No
Advice given Yes / No
units per day / week
Advice given Yes / No
Referred
Yes/No
Activity taken:
Other advice & support given. (Please comment)
Information & literature given (please comment)
Informed re Diabetes UK
Enter results onto surgery computer then file in patient’s notes
** If the patients requests - please give a copy of this filled in information sheet to them**.
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