Diabetes Template – SOAP note



Diabetes Subjective / HPI

Diabetes Presentation

When a patient presents for a diabetes follow-up visit you want to know what medications the patient is taking. Your dot phrase or smart phrase should include a list of the medications you usually prescribe. Including whether they are on ACE inhibitors or ARBs. Then you want to know if the patient has been compliant with the treatment. Followed by the report of any episodes of hypoglycemia.

Inquire about their routine retina exam with their ophthalmologist as well as any symptoms of diabetic neuropathy.

Another good thing to always review with the patient is lifestyle changes that can improve her diabetes, like exercise and healthy diet.

Diabetes Objective / Physical Exam

Diabetes Exam (PE)

A diabetic foot exam is recommended at least once a year. Look for ulcers and check pulses and do a monofilament test to screen for peripheral neuropathy. Foot amputations in patients with diabetic foot ulcers are preventable with early recognition and therapy.

Diabetes Assessment and Plan

Diabetes Plan

For accurate clinical documentation, always specify if the condition is controlled or uncontrolled. Outline your plan. Whether it is to continue the same medications, change them, or work on lifestyle interventions.

Standards of care for diabetes published by the American Diabetes Association (ADA), are good recommendations to follow for the management of diabetes. Things to keep in mind include: ensure patients has renal protection by using ACE inhibitors or ARBs and check microalbumin once a year. Reduce cardiovascular risk with the use of aspirin and statins and check lipid panel once a year. Refer to ophthalmology for a retina exam at least annually.

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