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Diabetes Practice Recommendations and Flow sheet
Patient Name _________________________
DOB___________
Sex: F
Key: N = Normal; A = Abnormal; R = Referred; *M = met;* U = unmet
1. Complete history & physical
Initial visit & annually
2. Diabetes Education (DSME/DULCE)
Initial, annually, and prn
3. Nutrition Counseling/Referral
Initial visit, annually, and prn
4. Physical Activity Counseling
Every visit
5. Psychosocial Counseling
Initial Social work/Psych and
prn
Every visit
6. Lifestyle/Behavior Change Goal(s)
Review
Goal: ______________________
7. Weight/Height/BMI/Waist Circ.
Every visit
8. Blood Pressure
Goal: < 130/80
9. Foot Inspection
Inspect for skin and nail lesions, calluses,
infection
10. Aspirin/Antiplatelet Prophylaxis
(If no contraindication)
11. ACE/ARB
If abnormal urine microalbumin
12. A1C
Individual goal based on patient risk
assessment
Intensive management A1C < 7%
Less intensive management A1C < 7.5 %
(Hypoglycemia unawareness/vulnerable
patient)
13. POC glucose
Every visit
14. Kidney Evaluation
GFR
(< 60 - abnormal)
Initial then minimally annually
Microalbumin/creatinine ratio
(> 30 - abnormal)
15. Total Cholesterol
16. LDL
Target: < 100; < 70 CHD
17. HDL
Target: > 40 Men; 50 Women
18. Triglycerides
Target: < 150
Every visit
Every visit
Every visit
Every 3 months
Every visit
If microalbumuria monitor every
3 months
Annually
Annually
Annually
Annually
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
M/U*
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
Date
Result
M
19. ALT
Caution with oral medications if abnormal
20. Dilated funduscopic eye exam
Consult/Results
21. Podiatric Exam Consult/Results
Every 3 months
21. Oral/Dental Consult/Results
Every 6 months
22. Influenza (Flu) Vaccine
23. Tdap Vaccine
24. Pneumococal Vaccine
Annually
One time as adult
Initial, repeat per ACIP
Initial and minimally annually
Initial and minimally annually
Date
Result
Date
Result
Date
Result
Date
Result
Date
Date
Date
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