Duke University’s ADA-Recognized Adult Education Program
Referral for Diabetes Self-Care Management Education (DSME)
PATIENT INFORMATION
Name:_____________________________________ DOB: ___________________MRN: ___________________
Address:___________________________________ City: ____________________State: ___________________
Zip: _________ Phone (H): ________________(W): ____________________Primary Language:__________________
Referring Provider: _______________________________________________Interpreter required: Y: _____ N: _____
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□ Type 1 □ Type 2 □ Gestational □ Pre-existing DM w/ preg □ Pre-diabetes □ Other_____________
Diagnosis:
Need for Education
New DM diagnosis: Urgent
Provider Comments:
Emergent DSME: (due to hypoglycemia, DKA
Recent ED visit, hospitalization, pregnancy
or Discharge follow-up)
Pre-Diabetes
Change in treatment plan
Inadequate glycemic control
Documented acute episodes of severe hypoglycemia or hyperglycemia occurring in the past year during which the
patient needed ER visits or hospitalization
High risk based on one of the following complications:
Hypertension
PVD
Pregnancy
CHD
Neuropathy
Dyslipidemia
Stroke
Obesity
Renal disease
Nephropathy
Mental/affective disorder
Non-healing wound
Retinopathy
Other __________________________
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Patients with special needs requiring individual DSME
Check all those that may apply:
Hearing
Vision (blind, seeing eye dog)
Physical
Language, interpreter required
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Insulin Pump & Sensor Programs
Saline Pump Training (SPT) 3 hrs (Wed or Thurs)
link to NIP visit on the following Monday
New pump initiation (NIP) 1.5 hrs (Mondays) linked to SPT
or CH
Diagnostic
3-5 days apart
Sensor Program (2 IND apts linked 3-5 days apart)
Patient-Owned Sensor Program (IND- must own CGM)
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Insulin Pump Review (IND- on current pump)
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□ Cognitive
□ Social, mental health
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Wheel Chair Bound
Other___________________
* Group Classes
TCD - Taking Charge of Your Diabetes
DNC - Diabetes Nutrition and Carb Counting
PDM - Pre-diabetes or PCOS
WLE-Weight
IPT
- Introduction
Loss and
to Pump
Exercise
Therapy
MPS-Meal Planning & Shopping for Diabetes
NDL-Nutrition for Dyslipidemia
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Insulin Pump Conversion (IND- new pump required)
( must have new pump)
* (IF PATIENT NOT APPROPRIATE FOR GROUP CLASS ABOVE)
Individual Appointments: with CNS, RN, CDE
IND
□ Recent hospitalization for DKA, hypoglycemia
(1.5 hours) □ Insulin Instruction
(MD attach insulin orders and algorithm)
□ Assisted Hypoglycemia/hypoglycemia unaware
□ Diabetes & Pregnancy
Diabetes
& Pregnancy
□ Other______________________
Individual Appointments: with RD, CDE
MNT
□ Diabetes Meal Plan
(1.5 hours)
□ Carb Counting
Must have
□ Celiac Disease
DM or preDM
Diabetes
diagno
Diagnosis
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Renal Disease with diabetes
Elevated lipids with diabetes
Other______________________
□ Other: ________________________
Referring Provider Signature:__________________________________________________
Date: _____/_____/_____
Scheduler Initials: _________ Appt with provider: _____________________________________
(ADEP referral 2/18/13)
Please fax referral to Duke University’s Endocrine appointment Hub : 919-479-2661