This document appears to be a flow sheet or encounter form for patients with diabetes and possible coronary artery disease. It includes sections for collecting past medical history, diagnostic and clinical data over time including glycemic control, symptoms, blood pressure, lifestyle factors like smoking and exercise, and medications including anti-platelets, ACE/ARB inhibitors, and statins. Fields are included to track values over time and note if treatment needs to be adjusted.

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