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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 Page 1 of 4 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. Page 2 of 4 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. Page 3 of 4 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. Page 4 of 4