Baptist Diabetes Center
Baptist Hospital
2010 Church Street, Suite 201  Nashville, TN 37203
Phone: (615) 284-2800 / Fax : (615) 284-4285
www.BaptistHospital.com/diabetes
Physician Order Form for Outpatient Diabetes Services
Patient Name
/
Last
Patient Primary Phone:
First
Middle Initial
/
Date of Birth
Secondary Phone:
Please check the box(es) next to your selections including diagnosis codes on page 2.
I. Advanced Care Nurse Practitioner Management Program An Advanced Nurse Practitioner (APN)
will prescribe and adjust medications for diabetes management. Patient will be followed until optimal blood glucose control is obtained.
 Insulin Management  Medication Management – Diabetes Center to calculate dose and adjust until target ranges met.
 Insulin Pump Management
 Management of Diabetes during Pregnancy
II. Diabetes Education Program taught by Registered Nurses and Dietitians specially trained and certified in
Diabetes Education.
 Group
Education
 Individual Education – MEDICARE REQUIRES documentation for individual consultations.
Diabetes Center
strongly recommends basic group education prior to individual education or consultation. Please indicate special considerations:
 Severe Speech  Hearing  Language  Mental Deficiency  Other
 Clinician Consultation for diabetes education
 Insulin Instruction or other Injectable (please specify injectable
)
 Please Specify Dose
OR  Initial dose to be calculated by Diabetes Center Staff
 Insulin Pump Instruction -  New to pump  Pump upgrade
 Continuous Glucose Sensor Monitoring–  72 hr. or  Personal Sensor (Insertion, removal and downloading of data
will be done per manufacturers guidelines. Results will be sent to referring physician with recommendations.)
 Registered Dietitian Consultation Special Instructions
III. Diabetes and Pregnancy Education Program taught by Registered Nurses and Dietitians specially trained
and certified in Diabetes Education.
 Gestational Diabetes Education(If ordering management of diabetes during pregnancy, management must be checked in Section I.
Individual Education (Pre-diabetes, Pre-existing Type 1 or Type 2) Special Instructions
 Insulin Instruction Only Type____________________
Dose________________
Other Collaborating Physician (Endocrinologist or Perinatologist)
Additional Information
Physician Signature (Required):
UPIN#
Date:
Physician Name: (Please Print)
Phone:
Fax:
Physician Office E-mail:
Best way to communicate:
 Email
Fax
Please complete page 2 of this form and fax with requested documentation to (615) 284-4285.
Baptist Hospital
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Physician Order Form for Outpatient Services
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Physician Referral and Order Form
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Please fax copies of patient’s demographic/contact information, most recent lab results
(i.e. A1c, GTT, lipids, etc.,), current medication list, medical problem list, insurance
ID card(s) and insurance information with physician order form to (615) 284-4285.
Patient Name
/
Last
First
Middle Initial
/
Date of Birth
Please make at least one selection per section
Diagnosis
ICD-9 Code:
250.00 Type 2 controlled
250.01 Type 1 controlled
250.02 Type 2 uncontrolled
250.03 Type 1 uncontrolled
277.7 Dysmetabolic syndrome
 Other
/
ICD9 Code
648.03 & 250 Type 2 Pregnant
648.03 & 250 Type 1 Pregnant
648.83 Gestational diabetes
648.84 Abnormal Glucose Tolerance of Mother Postpartum
790.29 Abnormal GT (pre-diabetes)
Description
Medical Status
 Newly diagnosed
 Severe hypo/hyperglycemia
AND / OR
 New to Insulin
 Nephropathy
Complications:
 New to oral agents
 Retinopathy
A1C or GTT Result:
_______________________ Date _________________
Diabetes during Pregnancy: EDC
Weeks Gestation
 Vascular Disease
 Obesity
 Foot problem
 Gastroparesis
 Other: _____________________________
 None Available – Diabetes Center to test
Target Blood Glucose (non-pregnant):
Pre-prandial: 80-120 mg/dl
Post-prandial: less than 160 mg/dl
 Pre-prandial: _______-________ mg/dl
 Post-prandial: less than __________ mg/dl
Target Blood Glucose (for Diabetes during Pregnancy):
Fasting 60-95 mg/dL
Pre-Meal Less than 110 mg/dL
2 hr pc – Less than 120 mg/dL
 Fasting
 Pre-Meal
 2 hr pc
mg/dL
mg/dL
mg/dL
Monitoring:  Patient is to monitor _____________ times/day. Current treatment:  oral medications  non-insulin  insulin
Supplies will be ordered from vendor of patient’s choice unless this box is checked. Pharmacy
Phone
 In case of hypoglycemia – treat per protocol below.
PROGRAM DESCRIPTIONS: For a complete list of description of our programs and/or protocols, please visit our website at
www.BaptistHospital.com/diabetes or call (615) 284-2800 to request a faxed copy.
DIABETES CENTER HYPOGLYCEMIA PROTOCOL: If the blood glucose is below 70 mg/dL, patient will receive 15 grams of
carbohydrate. After 15 minutes, recheck blood glucose. If low blood glucose persists, repeat above treatment and continue checking
until blood glucose is greater than 70 mg/dL. Follow with a protein snack if main meal is going to be delayed longer than 2 hours.
Notify physician and document in medical record the patient's signs and symptoms, blood glucose value, and treatment.
Diabetes Center Hypoglycemia Protocol for Pregnant Patients: If the blood glucose is below 60 mg/dL, patient will receive 15
grams of carbohydrate. After 15 minutes, recheck blood glucose. If low blood glucose persists, repeat above treatment and continue
checking until blood glucose is greater than 60 mg/dL. Follow with a protein snack if main meal is going to be delayed longer than 2
hours. Notify physician and document in medical record the patient's signs and symptoms, blood glucose value, and treatment.
SAINT THOMAS HEALTH SERVICES
Diabetes Center Referral
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