Diabetes Self-Management Education Record Patient Label Record level of competence and Initial: O=outcomes met; RT=reinforce teaching; NA=not applicable; P=prior knowledge Clinical Outcomes Information Source: Patient, Lab, Physician Office Time: Session 1 Session 2 Session 3 Session 4 Preprandial Blood Glucose Postprandial Blood Glucose Bedtime Blood Glucose Hemoglobin A1C (%) LDL HDL Triglycerides Checks feet/times per week Height: Weight: lbs lbs lbs lbs BMI: Goal #1: Met/New Goal: Progress/Barrier: Goal #2: Met/New Goal: Progress/Barrier: Pt will be able to: Discuss general facts of diabetes, identify personal type of diabetes Plan meals using their meal plan Correctly reads food labels and calculates exchanges Plan appropriate snacks Discuss special diet issues (alcohol, labels, heart healthy eating, sugar subs, eating out, grocery shopping, etc) Develop and appropriate physical activity program for themselves List appropriate physical activity for themselves, benefits/risks of activity and discuss nutrition changes needed for activity Identify type, dose, action and frequency of their medications Correctly draw up and administer insulin and discuss proper needle disposal Test blood sugar according to individual plan Meter: Demonstrate correct method of SMBS Target BS: to mg/dl Demonstrate correct method for testing ketones Use results of nutrition, activity, medication and blood sugar records to improve control Identify symptoms and treatment of and define hypoglycemia Discuss sick day management and effects of illness on diabetes Define hyperglycemia and its symptoms Discuss potential for complications of diabetes in relation to blood sugar Discuss eye care, how often to eye doctor Demonstrate proper foot care and complete self exam
Identify the need for screening tests: eg microalbumin, lipids, HbA1c Identify plan to quit smoking if appropriate Complete self-management goal sheet Utilize problem solving skills to make changes to improve control. Identify appropriate community resources Identify when to call health care team Discuss feelings related to having diabetes Discuss relation of stress to diabetes Involve family/friends in diabetes care Identify importance of preconception counseling Develop a plan of care for diabetes self-management during pregnancy Responsibilities of people with diabetes Initials/ Initials/ Initials/ Initial Assessment Materials Given- 1. Stepping Toward Control 7. Blood glucose log 2. Grief process 8. Patient bill of rights/responsibilities 3. Goals for control 9. Resources 4. Medic alert 10. Sample Menus 5. Guidelines for meal planning 11. Diabetes Outlook bag/ada box 6. Signs & symptoms hypo/hyperglycemia 12. Glucometer Nutrition Education Materials Given- Dates: 1. Medical Nutrition Therapy 2. Fabulous Fiber 3. Portion Sizes 4. Label Reading 5. Switch Ingredients 6. Exchange List 7. Plate Method 8. Not All Fats 9. Fast Food Guide Complications Prevention Class Materials Given- 1. Patient Bill of Rights/Responsibilities 2. Complications Pack/ Foot Screening 3. Sick Day Management/ Prevention/ Flu & Pneumonia Vaccinations BD Pamphlet 4. Benefits of Exercise BD Pamphlet 5. Medications 6. Stress Management BD Pamphlet 7. Outcomes Measures 8. Medical Identification
BARTON COUNTY MEMORIAL HOSPITAL DIABETES TEACHING PATIENT NAME: DOCTOR: COMMENTS: Signature: Signature: Signature:
Barton County Memorial Hospital Dietitian Diabetes Education Teaching Notes Time in: Time Time Time Time Time Education Materials Used / Medical Nutrition Therapy Basic Meal Planning Guidelines Fabulous Fiber Portion Sizes Label Reading Switch Ingredients Exchange List Plate Method Not all Fats Are Created Equal Comments: Signature:
BARTON COUNTY MEMORIAL HOSPITAL Complications Prevention Class Time in Time out Patient Name: Educational Materials Used: 1. Patient Bill of Rights/Bill of Responsibilities 2. Complications Pack / Foot Screening 3. Sick Day Management / Prevention / Flu, Pneumonia Vaccinations BD Pamphlet 4. Benefits of Exercise BD Pamphlet 5. Medications 6. Stress Management BD Pamphlet 7. Outcomes Measures 8. Medical Identification Patient Goals Met: Comments: Signature: