1. DIABETES (+/- coronary artery disease)
COLLABORATIVE FLOW SHEET/ ENCOUNTER FORM
♦ PATIENT NAME
PAST HISTORY
ALCOHOL OVERUSE ARRHYTHMIA: ATRIAL FIB ARRHYTHMIA: OTHER
♦ HSN # (OR OTHER UNIQUE PATIENT ID) ♦ GENDER Male
ARTHRITIS CANCER CARDIOMYOPATHY Female Undifferentiated
CHF CHRONIC LUNG DIS. DEPRESSION ♦ PHONE (INCLUDE AREA CODE) ♦ BIRTHDATE (DD-MMM-YYYY)
HYPERTENSION LIPID ABNORMALITY LIVER DYSFUNCTION
OBESITY PERIPH. VASC. DIS. RENAL DYSFUNCTION
CHART NUMBER PRACTICE NAME
STROKE/TIA SUBSTANCE ABUSE VALVULAR HD
♦ PROVIDER NAME PROVIDER ID # (MSP #)
♦ DIABETES YEAR OF DX: TYPE 1 TYPE 2 OTHER
♦ CAD ___CHRONIC ANGINA, YEAR OF DX: ___MI, YEAR OF DX: ___CABG, DATE: FRAMINGHAM
RISK
___ ___ACS/UNSTABLE ANGINA , YEAR OF DX: ___PCI/Stent. DATE: SCORE
DIAGNOSTIC/ CLINICAL DATA, BY DATE NEW DATA √ = RECALL
REVIEW ♦ = MANDATORY MOST RECENT DATA
FIELDS DATE OF VISIT:
URGENT CARE for DM &/or CAD
None (enter # of urgent visits)
ER/hospitalizations since last planned visit
CLINICAL STATUS
REVIEWED BLOOD GLUCOSE RECORDS REVIEWED
GLYCEMIC
CONTROL
♦ A1C EVERY 3 MONTHS: ENTER VALUE
TARGET ≤ 7.0% DATE OF TEST
DIABETES MEDICATIONS/INSULIN
REVIEWED ADJUSTED
Review & adjust PRN
SYMPTOMS STABLE: angina, palpitations, N/A STABLE NOT STABLE
CAD
shortness of breath, swelling, dizziness angina palp. SOB swelling dizzy
♦ BLOOD PRESSURE ENTER VALUE
HTN
TARGET ≤130/80 DATE OF TEST
3 TO 6 MONTHS
TARGET BODY MASS INDEX (BMI)
LBS KG
18.5 – 24.9 Height: Enter weight (LBS or KG)
LIFESTYLE
nd
♦ SMOKING Current 2 Hand Past Never
AEROBIC EXERCISE
YES NO IA
> 30 minutes most days, moderate intensity
OTHER LIFESTYLE FACTORS
REVIEWED
Stress, diet, alcohol
YES
♦ ANTI-PLATELET (ASA/OTHER)
NO: CI NT $ RF DA IA
YES
♦ ACE OR ARB
MEDICATIONS
NO: CI NT $ RF DA IA
YES
♦ STATIN
NO: CI NT $ RF DA IA
YES
♦ BETA-BLOCKER (IF CAD)
NO: CI NT $ RF DA IA
GENERAL REVIEW & ADJUST PRN REVIEWED ADJUSTED
LDL ENTER VALUE
Fasting lipid profile
3-6 mos (CAD)
Target < 2.5 mmol/L DATE OF TEST
(High-risk targets)
Annually OR
DYSLIPIDEMIA
ENTER VALUE
♦RATIO TOTAL CHOL
DATE OF TEST
(TOTAL CHOL/HDL)
TARGET RATIO < 4.0 ENTER VALUE
HDL
DATE OF TEST
LIPID RISK MODERATE HIGH
METER/LAB COMPARISON
FBG
COMPLETED
(Optimally, this is based on fasting glucose)
ANNUALLY AND/OR OTHERWISE NOTED
DILATED EYE EXAM DATE IA
EYE
Ophthalmologist, optometrist, retinal photo OPHTHALM OPTOM RETIN PHOTO
♦ MICROALBUMIN SCREEN ENTER NEG
Screen for
OR IA
Nephro-
RENAL
(<2.0 M: <2.8 F) (Albumin:creatinine VALUE POS
pathy
KIDNEY FUNCTION estimated CrCl SERUM CREATININE μmol/L
mL/min (Cockroft-Gault formula) DATE OF TEST
LOWER EXTREMITY EXAM
REVIEWED IA
NEURO-
PATHY
Check for peripheral anesthesia
HISTORY AND PHYSICAL: Check for pain,
REVIEWED
erectile dysfunction, gastrointestinal disturbance
ASSESS & DISCUSS SELF-MANAGEMENT REVIEWED
GOALS
ANNUAL INFLUENZA VACCINE COMPLETED DATE CI
OTHER
PNEUMOCOCCAL VACCINE COMPLETED DATE CI
♦ REFERRAL TO DIABETES EDUCATION, YES
CARDIAC REHAB, OR OTHER NO: NP TRP $ RF DA IA
CI – contraindicated NT – not tolerated $ – financial barrier RF – patient refused NP – no program available IA – Inappropriate DA – Didn’t Ask TRP– transportation barrier
Adapted from BCMA Collaborative Flowsheet FOR COMMENTS SEE NEXT PAGE Nov 8/06

2. DIABETES (+/- coronary artery disease)
COLLABORATIVE FLOW SHEET/ ENCOUNTER FORM
♦ PATIENT NAME
♦ HSN # (OR OTHER UNIQUE PATIENT ID) ♦ GENDER Male
Female Undifferentiated
♦ PHONE (INCLUDE AREA CODE) ♦ BIRTHDATE (DD-MMM-YYYY)
CHART NUMBER PRACTICE NAME
♦ PROVIDER NAME PROVIDER ID # (MSP #)
COMMENTS
Adapted from BCMA Collaborative Flowsheet Nov 8/06