Diabetes and Metabolic Flow Sheeto Type 1 o Type 2 o Unknown o Other: ______________________________

Year of diagnosis: ______________________ Height (cm): __________________________

PATIENT IDENTIFICATION

o Retinopathyo Diabetic Kidney Diseaseo Neuropathyo Hypoglycemic Unawareness

o CHDo PVDo Stroke/TIAo Other: ____________________________

DATE (YYYY/MM/DD):

LABS

AIC targetAIC resultBG lab │ Meter │ │ │ │ │

LDLTriglyceridesHDLNon-HDLCreatinine │ eGFR │ │ │ │ │Urine ACR

EXAM

Weight: Kg/Lbs Kg/Lbs Kg/Lbs Kg/Lbs Kg/LbsBP │ Home/AMBP │ │ │ │ │Foot exam ABN/N (if abnormal describe findings)Monofilament examLast eye exam (MM/YR)│ R - Referred RM - Reminded │ │ │ │ │

COU

NSE

LLIN

G Y - Yes N - No NA - Not applicable ü - DoneSmoking │ Cessation Counselled │ │ │ │ │Driver’s license: │ Counselled │ │ │ │ │Hypoglycemia counselling Sick day counsellingPreconception counsellingVaccine (pneumonia/flu) counselling

MED

ICAT

ION

S

Y - Yes N - No NA - Not applicable PD - Patient declined I - Intolerant → Unchanged C - Contraindicated In - insulin │ S - secretgogue │ │ │ │ │StatinOther lipidACEi/ARB

PR 60045 (2018/08/31)

Howtousethisflowsheet:• TheItemsonthisflowsheetincludedataforcalculatingscorecardindicatorsandsomecommonlyrecordedvalues.Thereisspacetoadd

additionalitems.• Pleaseuseconsistentcharting• Ifprocessisnotdone,leavecellblank• Labs

o IndicatepersonalizedA1Ctarget,ifitisunchangeddrawfornextvisitarrowà.Arangeisacceptable.Itwillbeenteredinscorecarddatabaseatuppervalue.

o Ifthelabshavebeendonewithin2weeksofclinicalvisit,listundertheclinicvisit,ifthelabsaremorethan2weeksfromthevisitdatetheyshouldbedenotedintwodifferentcolumns

• Examo RecordofficeBP.IfawarethathomeorambulatoryBPmonitoringisnormal,mayrecordhomeBPvalueorT(intarget)o FootexamRecordNorABN,mayuseowncodingtorecordfindings.Iftheexamwasnotdoneonthatvisitleaveblanko Eyeexam,notemonthandyear.Ifpatientisoverdueandyouhaveremindedthem,recordRM.IfyouhavereferredthemrecordR.

Ifeyeexamnotaddressed,leaveblank.• Counselling

o RecordsmokingY/N.Ifcounselledoncessation,check√.Ifsmokingnotaddressed,leaveblanko Recorddriver’slicenseY/N.Ifyoucounselledondrivingsafely,check√.Innotcounselled,leaveblanko Hypoglycemiamanagement,sick-daycounselling,preconceptioncounselling-ifyoucounsel,check√.NAfornotapplicable.

Theindicatorcalculationswillonlyapplytothosewhorequirecounselling.o Youmayleavevaccinationblank,itiscurrentlynotanindicator.IthasbeennotedifK045billingcodeisbeingused.

• Meds:o Indicateinsulinorasecretogogueo Listnameanddoseofmedicationsatvisit.àatnextvisitindicatesnochange.o StatinandACEi/ARB.MayindicateNA(notindicated).Ifrecommended,butthepatientdeclinesrecordPD.Ifpatientisintolerant

noteI.CounsellingRecommendations(alltakenformtheDC2018guidelines):

• Vaccines:annual influenza vaccination during. Pneu-P-23 vaccination should be offered to persons with diabetes aged 19 to 64 years. A 1-time revaccination is recommended for those ≥65 years of age (if the original vaccine was given when they were <65 years of age). For people with diabetes ≥65 years or with an immunocompromising condition (e.g. end stage renal disease), Pneu-C-13 vaccine should be administered first, followed at least 8 weeks later by Pneu-P-23 vaccine. In people who have already received Pneu-P-23, at least 1 year should elapse before they are given Pneu-C-13.

• Hypoglycemia:Mild-to-moderatehypoglycemiashouldbetreatedbytheoralingestionof15 gcarbohydrate,preferablyasglucoseorsucrosetabletsorsolution.Thesearepreferabletoorangejuiceandglucosegels;retestBGin15minutesandre-treatwithanother15 gcarbohydrateiftheBGlevelremains<4.0 mmol/L.Severehypoglycemiainaconsciouspersonwithdiabetesshouldbetreatedbyoralingestionof20 gcarbohydrate,preferablyasglucosetabletsorequivalent.BGshouldberetestedin15minutesandthenre-treatedwithanother15 gglucoseiftheBGlevelremains<4.0 mmol/L.Oncethehypoglycemiahasbeenreversed,thepersonshouldhavetheusualmealorsnackthatisdueatthattimeofthedaytopreventrepeatedhypoglycemia.Ifamealis>1houraway,asnack(including15 gcarbohydrateandaproteinsource)shouldbeconsumedForpeopleatriskofseverehypoglycemia,supportpersonsshouldbetaughthowtoadministerglucagon

• Driving:HaveBGmonitoringequipmentandsuppliesofrapidlyabsorbedcarbohydratewithineasyreachShouldconsidermeasuringtheirBGlevelimmediatelybeforeandatleastevery4hourswhiledrivingorwearareal-timeCGMdevice.ShouldnotdrivewhentheirBGlevelis<4.0 mmol/L;theyshouldnotdriveuntilatleast40minutesaftersuccessfultreatmentofhypoglycemiahasincreasedtheirBGleveltoatleast5.0 mmol/L.Refrainfromdrivingimmediatelyiftheyexperienceseverehypoglycemiawhiledriving,andnotifytheirhealth-careproviderassoonaspossible.Health-careprofessionalsshouldinformpeoplewithdiabetestreatedwithinsulinsecretagoguesand/orinsulintonolongerdrive,andshouldreporttheirconcernsabouttheperson'sfitnesstodrivetotheappropriatedrivinglicensingbody:Anyepisodeofseverehypoglycemiawhiledrivinginthepast12monthsORMorethan1episodeofseverehypoglycemiawhileawakebutnotdrivinginthepast6monthsforprivatedrivers,andinthepast12monthsforcommercialdrivers.

• Sickdaymanagement:Whenpatientsareillwithvolumecontractionduetodiarrheaorvomitingtheyshouldbeinstructedtoholdmedicationsthatcanworsenkidneyfunction,precipitatehypoglycemiaorleadtoeuglycemicDKA.Theseinclude:SulfonureasAce-I,Diuretics,Metformin,ARB,NSAIDs,SGLT-2i.Patientsshouldbeinstructedtochecktheirbloodsugarsmorefrequentlyandifoninsulintheymayrequireadditionalcorrectionstobringdownhighernumbers.

• Preconception:Allwomenwithpre-existingdiabetesshouldreceivepreconceptioncaretooptimizeglycemiccontrol,assessforcomplications,reviewmedicationsandbeginfolicacidsupplementation.Effectivecontraceptionshouldbeprovideduntilthewomanisreadyforpregnancy.WomenshouldtargetanA1C≤7.0%(ideally≤6.5%ifpossible)priortopregnancy.Womenshouldconsidertheuseofthecontinuousglucosemonitorduringpregnancytoimproveglycemiccontrolandneonataloutcomes.

• Smoking(fromtheCanadianSmokingCessationClinicalPracticeGuidelines-2012):Tobaccousestatusshouldbeupdatedregularlybyallcareproviders.Healthcareprovidersshouldclearlyadvisepatientstocutdownorquit,multiplecounsellingsessionsincreasesthechanceofsuccessfulcessation.Combinationcounsellingandsmokingcessationmedicationismoreeffectivethaneitheralone.Web-basedandhelplinemethodshavebeenshowntobeeffective.https://www.smokershelpline.ca/