Outpatient Program Multidisciplinary Team Discharge Summary m
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1 Diabetes Center Outpatient Program Multidisciplinary Team Discharge Summary m PATIENT: DOB:, Person instructed: Patient Other : Date of Completion: Diabetes Education Attended: Day 1: BG s: ac lunch pp lunch Day 2: BG s: ac lunch Medical Nutrition Therapy calories carb choices/day Weight Pre program weight Post program weight BG Monitoring Diabetes Meds Tobacco Status Stress Foot Exam Physical Activity Type meter: Smokes: yes no Referred to Smoking Cessation Program: yes no Stress/anxiety/depression sx: yes no Attended Stress Management Class: yes no Completed: yes no Pre program: At follow up: Follow up Attended: Yes No Via Mail: Yes No Comments: Physician Diabetes Educator American Diabetes Association Clinical Practice Recommendations include but are not limited to: *Annual lipid panel, microalbumin, urinalysis for protein, BUN/Cr, and dilated eye exam. *Quarterly HgbA1c. *EKG and stress test as indicated. Revised 10/06, 1/07, 3/08 DCTR0003
2 Diabetes Center Education Record Patient Name, Date of Staffing (All Clinicians Attending) Patients Special Interests: Diet SMBG Meds All Other: EDUCATION PLAN Attend 2 day OPP classes and follow up class Individual counseling session Individual nutrition session Individual RN session Obtain BG meter Other Pre and Post program Knowledge/Skill Level: 1 No knowledge 2 Needs review/assistance 3 Demonstrates competency N/A Not applicable Patient/Significant Other is able to: I. Diabetes Disease Process Overview A. Define diabetes in simple terms. B. State own type of diabetes. C. State diabetes is treated by meal plan, exercise, medication, monitoring, and education. II. Monitoring A. State purpose and frequency of monitoring BG, ketones, HgbA1c, and when to contact health care team with results. B. Perform glucose monitoring/ketone testing and record results correctly. C. State target blood glucose and HgbA1c goals. III. Medications A. State name, action, duration, side effects, and time to take medication. B. Correctly draw up and administer insulin. C. Describe site selection and rotation for insulin injections. IV. Physical Activity A. List appropriate types of exercise. B. State relationship of exercise to blood sugar. C. State the benefits/risk(s) of exercise and precautions to follow. V. Nutritional Management A. Describes relationship of food, meal times, and Body weight to BG levels B. Identifies guidelines for food selections. C. States appropriate meals using meal plan and carb choices. D. Identifies guidelines for reading labels. E. Identifies guidelines for eating in restaurants. Pre program Teaching: Date/Initials Post program Follow up Needed/Comments Revised 7/05, Reviewed 1/07 DCTR0004A
3 Patient/Significant Other is able to: VI. Psychosocial Adjustment A. Describes how stressful conditions affect BG and identifies ways to manage stress. B. Identifies feelings which may accompany having diabetes. VII. Acute Complications A. State the causes, signs, symptoms, and prevention of hyperglycemia. B. Explain proper treatment of hyperglycemia. C. State the causes, signs, symptoms, and prevention of hypoglycemia. D. Explain proper treatment of hypoglycemia. E. State sick day guidelines and when to contact health care team. VIII. Chronic Complications/Risk Reduction A. State the relationship between blood glucose control and the development/prevention of long term complications. B. State benefits, risk, and options for improving blood sugar control. C. State relationship between blood pressure and lipid control in the prevention/control of cardiovascular diseases (UKPDS). D. State principles of skin, dental, and foot care. E. Describe symptoms of skin and foot problems and demonstrate foot exam. F. State when to seek medical advice and treatment. IX. Goal Setting and Problem Solving A. State benefits of making appropriate lifestyle changes. B. Identifies changes that need to be made and sets goals. C. Verbalize need for and frequency of health care follow up. D. List at least two appropriate community resources. X. Preconception Care, Pregnancy, GDM Management (if applicable) A. State relationship between blood sugar control and pregnancy outcome. B. Explain risk of maternal and fetal complications Due to diabetes XI. Steps to Better Control A. Identifies major components of diabetes management. B. Discusses pattern management. C. Acknowledges the availability of long term follow up through the Diabetes Center and other facilities. Signatures/Initials: Nurse Educator Nurse Educator Revised 7/05, 1/07, 3/08 Pre program Teaching: Date/Initials Post program Follow up Needed/Comments Nutritionist Nutritionist DCTR0004B
4 Diabetes Center Patient Outcome Data Patient Name:, DOB: OPP: Consult: Program Start Date: Post Program Date: Clinical Data Clinical Indicator Weight Foot Inspection Goal Goal Goal Goal Gestational Birth Weight Pre program Y N Nutrition Exercise SBGM Medications/Lifestyle Post program Y N Goal Achievement: 4 = always 3 = most of the time 2 = sometimes 1 = never DCTR0005 Revised 7/05, 1/07
5 Meal Plan, Name Date Nutritionist Phone Remember!!!!! Total Needed for Each Day: 1 Carbohydrate Choice = 15 grams of Carbohydrate 1 Fat Choice = 5 grams of Fat Carbohydrate Choices ( grams carboydrate) Fat Choices ( grams fat) Breakfast Carbohydrate Choices Grams(g) of Carbs Non starchy Vegetables Meat (s) Fat (s) Lunch Carbohydrate Choices grams(g) of Carbs Non Starchy Vegetables Meat (s) Fat (s) Supper Carbohydrate Choices grams(g) of Carbs Non starchy Vegetables Meat (s) Fat (s) Morning Snack Afternoon Snack Evening Snack Revised 2/1/07 DCTR0006
6 DIABETES CENTER Buffet Lunch TUESDAY Please circle your selections MEAT GROUP Swiss Chicken Grilled Tenderloin Steak SELECT CARBOHYDRATE SERVINGS: 1 carbohydrate serving...baked Potato, 3 ounces 1 carbohydrate serving...dinner Roll, 1 roll 1 carbohydrate and 1 fat serving...graham crackers, 3 Squares 1 carbohydrate serving...fruit flavored yogurt, 4 ounces 1 carbohydrate serving...fruit cup, ½ cup 1 carbohydrate serving...skim milk, 1 containter (1 cup) SELECT FAT SERVINGS: 1 fat serving...margarine, 1 teaspoon 1 fat serving...regular salad dressing, 1 Tablespoon FREE FOODS: SELECT AS MANY OF THESE AS YOU WANT Revised 12/06 Revised 01/07 Revised 03/08 Iced tea Diet drink Plain yogurt (for potato) Cooked broccoli Cooked carrots Tossed Salad Fat free salad dressing Sugar free Jello DCTR0007
7 DIABETES CENTER Buffet Lunch WEDNESDAY Please circle your selections MEAT GROUP Beef Stew (counts as meat and 1 carbohydrate serving) Grilled Tuna Steak with Dill SELECT CARBOHYDRATE SERVINGS: 1 carbohydrate serving...navy Bean Soup, 1 cup 1 carbohydrate serving...rice, 1/3 cup 1 carbohydrate and 1 fat serving...cornbread, 1 muffin 1 carbohydrate serving...wheat crackers, 4 crackers 1 carbohydrate serving...angel food cake, 1 slice 1 carbohydrate serving...sliced peaches, ½ cup 1 carbohydrate serving...skim milk, 1 container (1 cup) SELECT FAT SERVINGS: 1 fat serving...margarine, 1 teaspoon 1 fat serving...regular salad dressing, 1 Tablespoon 1 fat serving...tartar sauce, 1 Tablespoon FREE FOODS: SELECT AS MANY OF THESE AS YOU WANT Iced tea Diet drink Green beans Tossed salad Fat free salad dressing Sugar free Jello Dill pickles Revised 12/06 Revised 01/07 Revised 03/08 DCTR0008
8 DIABETES CENTER Buffet Lunch FRIDAY Please circle your selections MEAT GROUP Seasoned Baked Fish Sliced Roast Beef, Ham, Turkey, and/or Swiss Cheese SELECT CARBOHYDRATE SERVINGS: 1 carbohydrate and meat... Seafood Gumbo, ½ cup 1 carbohydrate and 1 fat serving... Seafood Dressing, ½ cup 1 carbohydrate serving... Baby Lima Beans, ½ cup 1 carbohydrate serving...wheat bread, 1 slice 1 carbohydrate serving...wheat crackers, 4 crackers 1 carbohydrate serving...fresh orange wedges, ½ cup 1 carbohydrate serving...skim Milk, 1 container (1 cup) SELECT FAT SERVINGS: 1 fat serving...regular mayonnaise, 1 teaspoon 1 fat serving...regular salad dressing, 1 Tablespoon 1 fat serving...tartar sauce, 1 Tablespoon FREE FOODS: SELECT AS MANY OF THESE AS YOU WANT Iced tea Diet drink Stewed Tomatoes Tossed Green Salad Dill pickles Fat free mayonnaise Fat free salad dressing Mustard Revised 12/06 Revised 01/07 Revised 03/08 DCTR0009
9 Diabetes Center Behavior Change Goals Name: Date:, Check one goal in each category: Goal 1. Nutrition/Weight Loss I will replace with. I will not skip meals and will space meals 4 5 hours apart. I will count carbohydrate portions at each meal. I will limit fried foods to not more than once per week.. 2. Exercise I will exercise days a week for minutes. I will see my doctor for an EKG or stress test for exercise approval.. 3. Monitoring I will check my blood sugar times per day and record. I will check ketones if blood sugar is greater than Medications/Lifestyle I will take my medications as prescribed. Treat hypoglycemia with glucose tabs. I will cut down to cigarettes per day and/or begin a Stop Smoking program. I will use stress reduction methods such as listening to music or going for a walk. I will inspect my feet daily.. Patient Signature Educator Signature Revised 1/07 DCTR0010
10 Diabetes Center Follow up/goal Evaluation Name: Date:, Date of Birth: Present weight: Previous weight: Do you check your feet everyday? Yes No Todays fasting blood sugar How often are you checking blood sugars? How are you doing with carbohydrate counting? Are you physically active? Yes No Type of activity How often? How long? ****************************************************************************** STAFF USE ONLY: PROGRESS TOWARD GOALS: Rating scale: 4 = always, 3 = most of the time, 2 = sometimes, 1 = never 1. Nutrition/Weight Loss Achieved Continued Modified 2. Exercise Achieved Continued Modified 3. Monitor blood sugar Achieved Continued Modified 4. Medications/Lifestyle Achieved Continued Modified EVALUATION OF LEARNING/BEHAVORIAL OBJECTIVES: Excellent Acceptable Poor COMMENTS Physician Revised 7/05, 1/07 Educator DCTR0011
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