Download For Primary Care Providers Diabetes Component

MEDICAL RECORD DOCUMENTATION
REVIEW STANDARDS
For Primary Care Providers
Diabetes Component
ELEMENTS
GUIDELINES
1. Baseline Medical History
Elements of the baseline medical history of particular
concerns in patients with diabetes include the following:
- current Symptoms
- history of glucose control (results of lab studies related
to the diagnosis of diabetes)
- results of glucose self-monitoring.
- eating patterns, nutritional status, weight history,
growth and development in children and adolescents
- frequency, severity of acute complications such as
ketoacidosis and hypoglycemia
ADA Clinical Practice
Recommendations 2008
AHCA Diabetes Guidelines
- symptoms and treatment of chronic eye, kidney,
nerves, foot, GI, GU, heart, vascular complications
- history of ulcers or amputations
- current medications
- tobacco and alcohol use
- lifestyle, exercise, cultural, psychological
educational, and economic factors and beliefs that
might affect management of diabetes
2. Baseline Physical Exam
ADA Clinical Practice
Recommendations 2008
AHCA Diabetes Guidelines
A baseline physical examination must be performed. If
unable to perform the exam on the initial visit a plan
for must be included:
- height and weight (with comparison to norms in
children and adolescents)
- blood pressure including orthostatic changes
- ophthalmoscopic/fundoscopy (referral to Opt
preferred)
- oral, dental
- thyroid palpation
- cardiac
- abdominal (e.g., for hepatomegaly)
- evaluation of pulses (by palpation and
auscultation)
- hands/fingers
- feet
- skin (including insulin injection sites)
- neurologic
- signs of diseases that can cause secondary diabetes
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3. Interim History
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
An interim history for the evaluation of glucose
control and disease complications must be obtained at
each diabetic visit and include the following:
- frequency, causes, and severity of hypo or
hyperglycemia
- results of glucose self monitoring glucose
- changes patient made to the therapeutic regime
- problems with adherence
- symptoms suggesting complications of diabetes
- other medical illnesses
- psychosocial issues
- lifestyle changes
- continuation of tobacco and/ or alcohol use
4. Follow-up Examination
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
Routine follow-up diabetic examinations are indicated at
least every 3 months for diabetics who are not meeting
treatment goals and at least every 6 months for those
who are meeting gorals. The following must be
addressed:
- weight
- blood pressure
- fundoscopy
- foot examinations
- follow-up on abnormalities from previous visits
5. HbA1c Control
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines, HEDIS
HbA1c levels are required every 3 months in patients
who are not meeting treatment goals and every 6 months
if treatment goals are being met.
The goal HbA1c is 7 %.
6. Lipid Control
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines, HEDIS
Fasting lipid profiles are indicated annually.
Goals:
LDL < 100mg/dL
HDL > 45 in men and > 50 in women
Triglycerides < 150
7. EKG
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
A baseline EKG is indicated for all adult patients (21
years and older) with diabetes.
8. Serum Creatinine
ADA Clinical Practice
Recommendations 2003
A baseline serum creatinine level is indicated for all
adult patients (21 years and older) with diabetes and in
children with diabetes if proteinuria is present.
9. Thyroid-Stimulating Hormone
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
A baseline thyroid-stimulating hormone (TSH) levels
is indicated for all patients with Type 1 diabetes. In Type
2 if clinically indicated.
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10. Urinalysis
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
A baseline urinalysis for glucose, protein, and sediment
is indicated for all patients with diabetes.
11. Microalbumin
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
An annual test for the presences of microalbumin in
urine is indicated for all patients with diabetes.
Screening can be performed by the following methods:
1. Albumin-to-creatinine ratio in a random, preferably
morning, spot urine. This method is strongly
encouraged by the ADA.. Normal is < 30.
The following methods are rarely necessary:
2. 24 hr. urine collection with creatinine, allowing
for the simultaneous measurement of creatinine
clearance.
3. Timed (e.g., 4 hours or overnight) urine collection.
12. Foot Exams and Care
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
Routine foot exams are indicated for all patients with
diabetes.
1. An annual, comprehensive foot exam includes
- foot structure and biomechanics
- vascular status (including pulse)
- skin integrity
- neurological status/protective sensation (SemmesWeinstein monofilament test)
2. Routine visual inspection of the feet is required at
each visit for evaluation of diabetes. The inspection
should include as a minimum:
- skin integrity
- gross adnormalities
- color
- temperature
3. Patient with neuropathy are required to have a visual
inspection of the feet performed at every office visit
regardless of the presenting complaint.
Refer high-risk patients to Podiatry.
Educate about prevention of foot problems.
13. Dilated Eye Exam
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines, HEDIS
Dilated eye exam by optometrist or ophthalmologist
- in Type 1 DM: within 3-5 yrs. after onset of DM.
- in Type 2 DM: shortly after the diagnosis of DM.
Repeat exams annually thereafter.
14. Documentations of Results of
Dilated Eye Exams
HEDIS
Results of the dilated retinal exam must be present
on the record.
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15. Influenza Vaccination
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
Influenza vaccine every year.
16. Pneumococcal Vaccination
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
The pneumococcal vaccine is indicated for all patients
with diabetes.
Note: One time re-vaccination is recommended for
patients over 65 who were 59 years old or younger
when they were immunized.
17. Diabetic Education and
Nutrition Counseling
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
Appropriate diabetic and nutritional education and
counseling, as defined by the ADA and the Florida
AHCA Diabetes Guidelines, must be documented at
each educator if necessary.
18. Antiplatelet therapy
ADA Clinical Practice
Recommendations 2003
AHCA Diabetes Guidelines
- ASA (75-325mg/day) in all adults with DM and
macrovascular disease educator if necessary.
- Consider ASA for primary prevention patients with one
or more other risk factors for CVD.
19. Appropriate Referral and Follow-up
ADA Clinical Practice
Recommendations 2003
HEDIS
Consultations for specialized services, such as podiatry,
endocrinology, cardiology, neurology, etc., are ordered
when the patient’s condition warrants.
Results of the consult should be on the record in a timely
manner.
Consults are signed and dated and appropriate follow-up
of specialist’s recommendations is noted.
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