brevaDiabetes follow-up
Encounter
Patient name: [ ] Date of birth: [ ] Date and time of encounter: [ ] Clinician: [ ]
Interval history
Changes since the previous visit: [ ] Low blood sugar episodes, timing and treatment as reported: [ ] Medication and insulin use as reported, adherence and adverse effects: [ ] Diet, activity and barriers to self-management: [ ]
Glucose data
Most recent A1C with date: [ ] Home glucose or continuous glucose monitor data reviewed, with dates and source: [ ]
Monitoring
Vitals measured today, with units: [ ] Foot examination performed and findings: [ ] Eye examination status and date: [ ] Kidney monitoring results with dates: [ ] Lipid results with date: [ ]
Assessment and plan
Current control and supporting data: [ ] Medication decisions and rationale: [ ] Agreed targets: [ ] Orders, referrals and education provided: [ ]
Follow-up
Follow-up timing and purpose: [ ] Return precautions discussed: [ ] Patient questions and understanding: [ ]