Premier Home Health Care
Transitional Care
Visits List
NP DIABETES CLINICAL PATHWAY - Visit 2
Validation
1
Assessment
2
Nutrition
3
Physical Exam
4
Lab Data
5
Education & Equipment
6
Plan
7
Signature
Interim history (iincluding adverse effects of medications)
Has patient seen PCP or specialist
Yes
No
Notes:
Meds reviewed and reconciled
Oral hypoglycemics
Yes
No
Why:
Insulin
Yes
No
Long-Acting
Short-Acting
ACEI/ARB (if not, why not)
Yes
No
Why:
ASA (if not, why not)
Yes
No
Why:
Statin (if not, why not)
Yes
No
Why:
Antihypertensives (if needed)
Yes
No
Others (Specify)
Tolerating diet
Yes
No
Checking blood sugars
Yes
No
Following medication regimen
Yes
No
Review finger stick log
Yes
No
NA + Diet
Well balanced diet
Yes
No
No concentrated sweets
Yes
No
Current Weight
General Appearance (Assess vital signs Review physical exam, with attention to any complaints and prior positive findings, including skin and feet)
O2 Saturation
Blood Pressure
Respiratory Rate
Temprature
Pulse
Select:
Regular
Irregular
Afih
Neck Exam
Distended Neck Veins
Bruits
Lung Exam
Select:
Rales
Rhonchi
Breath Sounds
Cardiac Exam
Select:
Murmers
Rubs
Gallops
Abdominal Exam
Select:
Ascites
Hepatomegaly
Extermities
Edema (how much)?
Integument (Ulceration?)
Neurologic (loss of sensation, or ankle reflexes, in feet)?
Lab Tests (Review all lab data from prior visits, Order additional labs as needed)
CBC
HgA1C (If Diabetes)
Lipid Profile
Urinalysis
Urine microalbumin
Reinforce education on all issues covered in Visit 1 Especially: Medication review, Lab review (discuss HgbA1C), Review glucose log, Smoking cessation, Diet and activity
Glucose monitor in home
Yes
No
Educated on
Use of insulin (if needed)
Yes
No
Home glucose monitoring
Yes
No
HghAiC target
Yes
No
Complications of DM
Yes
No
Foot Safety
Yes
No
Need for ophthal, podiatry checks
Yes
No
Nephrology consult if needed
Yes
No
Smoking cessation (If needed)
Yes
No
Final Medication Reconciliation
Yes
No
"Teach back" method used
Yes
No
Follow up on appointments planned and/or needed
Yes
No
Order lab tests , xrays, etc needed since last visit
Yes
No
Give immunizations decided on at Visit 1 (specify)
Flu
Yes
No
Pneumonia
Yes
No
Shingles
Yes
No
Instructions Report
Report with instructions left with patient
Yes
No
Report Sent To
Care Team
Yes
No
PCP
Yes
No
Specialist
Yes
No
CHHA (If appropriate)
Yes
No
Finished
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Validation states
2
Alerts
3
Payment Info
4
Other Info
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