DM clinic visit

[comment memo="fill out"]
Pediatric Diabetes Clinic Note
Consultant: [textarea cols=40 rows=1 default=" Dr."]
Date: [date] (M-D-Y)
Patient accompanied by: [select name="Q1" value="mother|father|mother,father"][text default="_"]
[comment memo="fill out"]
___________________________________
Chief Complaint/Reason for visit: [textarea cols=40 rows=1 default=" Diabetes"]
In Summary:
This is a [textarea cols=5 rows=1 default="_"] [select value="y/o|m/o"] [select value="F|M"] , with [select value="Type 1 diabetes | Type 2 diabetes | diabetes"]. [select value="He|She"] was diagnosed on [textarea cols=60 rows=1 default="_, on MDI insulin regimen with iCGM, with excellent/good/fair/poor glycemic control."].
Problem list:
1. Diabetes, [select value="Type 1|Type 2"]
[textarea cols=60 rows=1].The patient [select value="is presenting to our clinic for follow-up of|was referred to our clinic for evaluation of"] [textarea cols=60 rows=1 default=" diabetes. Last seen on _"].
[comment memo="may skip text"]
___________________________________
HPI:
-Family diabetes concerns today are:
[textarea cols=60 rows=3 default="1.
2.
3."].
ROS:[comment memo="fillout"]
[checklist name="99" value="poor appetite/caloric intake|weight loss/poor weight gain|abdominal pain|nausea/vomiting|diarrhea|constipation|polyuria/polydipsia|heat or cold intolerance|skin/hair changes|headache|vision changes|fatigue|fever|arthralgia|rashes|lymphadenopathy"]
Puberty:[comment memo="will disappear"] [select name="Q11" value="Denies new puberty changes|Pubertal"] [conditional field="Q11" condition="(Q11).is('Pubertal')"] [textarea cols=65 rows=1 default="_Menarche at age_. Last menstrual period_."].[checkbox value="denies discharge or Lesion|denies abnormal vaginal bleeding|denies amenorrhea|denies irregular monthly periods"]
[/conditional]___________________________________
INSULIN THERAPY:[comment memo="fillout"]
-Basal insulin ([select value="Lantus/Glargine|Levemir/Detemir|Tresiba/degludec"]) = [textarea cols=5 rows=1 default="_"] units [textarea cols=5 rows=1 default="at _"]
-Bolus insulin ([select value="NovoLog/Aspart|Humalog/Lispro|Apidra/Glulisine|Fiasp"]) = [select name="Q2" value="fixed|ICR"][conditional field="Q2" condition="(Q2).is('fixed')"] [textarea cols=5 rows=1 default=" _"] units premeals [textarea cols=30 rows=1 default="and _ units pre-snacks."]
[/conditional][conditional field="Q2" condition="(Q2).is('ICR')"]: 1 unit per [textarea cols=5 rows=1 default="_"] gram CHO premeals. [textarea cols=30 rows=1 default="Pre-snacks 1unit:_gms."]
[/conditional] ISF: [textarea cols=5 rows=1 default="_"], Target 100 mg/dL. [select value="(using sliding scale)| "]
-TDD = [textarea cols=5 rows=1 default="_"] units/kg/day ([textarea cols=5 rows=1 default="_"]% basal, [textarea cols=5 rows=1 default="_"]%bolus)
[checklist value="Rotates site of insulin injections|Administering all the insulin doses prior to meals|Missing doses"]
[+] Insulin injections are given by [textarea cols=30 rows=1 default="_ patient, mother, _"].
[comment memo="fillout"]
GLYCEMIC CONTROL: [comment memo="fillout"]
TAR [textarea cols=5 rows=1 default="_"]%
TIR [textarea cols=5 rows=1 default="_"]%
TBR [textarea cols=5 rows=1 default="-"]%
Sensor use [textarea cols=5 rows=1 default="-"]% for [textarea cols=5 rows=1 default="14 days"]
GMI: [textarea cols=5 rows=1 default="_"]
Interpretation: [textarea cols=65 rows=4 default="_Persistent hyperglycemia throughout the day/night. Hyperglycemia throughout the day secondary to excessive carb intake and frequent snaking with lack of structured meal schedule"].[checklist value="Significant episodes of hypoglycemia|Recognizes the symptoms of low blood glucose|Need to use glucagon, or episode of seizures due to hypoglycemia|Recurrent DKA"]
[textarea cols=60 rows=1 default="[+] last DKA _ (on diagnosis)"]
DIET: [comment memo="fillout"]
[checklist value="Structured meal schedule| Understands carb counting concepts|Perform carb counting|Frequent snacking|High carb intake|Picky eater|Poor dietary habits"]
EXERCISE: [comment memo="fillout"]
[checklist value="Regular exercise|Participate in sports|Sedentary lifestyle"]
PSYCHOSOCIAL:[comment memo="fillout"]
[x] Lives with [textarea cols=30 rows=1 default="_both parents"].
[x] Diabetes primarycare giver is [textarea cols=30 rows=1 default="_"].
[x] Education/Work structure: [textarea cols=30 rows=2 default="Father works as_, mother works as_ /housewife"].
[x] School: Grade[textarea cols=30 rows=1 default="_"].
[checklist value="Frequent school absences"]
Challenges are: [comment memo="will disappear"][checkbox value="Family conflict|Poor parenting |Diabetes burnout|Anxiety or Depression|Fear of hypoglycemia|Poor socioeconomic status|Adolescent rebellion"]
FAMILY HX
-[checklist value="FHx of Diabetes|FHx of autoimmune diseases|FHx of consanguinity"]
DIABETES CARE ASSESSMENT:[comment memo="fillout"]
-[select value="Excellent|Good|Fair|Poor"] adherence to blood glucose monitoring and insulin administration.
-[select value="Excellent|Good|Fair|Poor"] diabetes control.
-[checklist value="recurrent hospitalization due to diabetes"]
___________________________________
PHYSICAL EXAM [textarea cols=60 rows=1 default="( done in presence of _, with patient/guardian permission)"].
[textarea cols=60 rows=2 default="GEN: Awake, alert and oriented. No acute distress. vitals reviewed. Healthy appearing, hydrated and nourished."]
[textarea cols=60 rows=1 default="HEAD: atraumatic, normocephalic."]
[textarea cols=60 rows=2 default="ENT: Moist mucus membranes. Normal eyes, conjunctiva clear. No abnormal eye movement."]
[textarea cols=60 rows=2 default="NECK: Thyroid is normal in size, no goiter. no nodules or tenderness."]
[textarea cols=60 rows=1 default="PULM/CVS: Regular rate, no tachypnea or no increase WOB."]
[textarea cols=60 rows=2 default="ABDOMEN: soft, non-tender, non-distended, _no organomegaly or masses. _no striae."]
[textarea cols=60 rows=3 default="NEURO/MSK:Alert, no focal findings, PERRL, _ optic disc, deep tendon reflexes normal and symmetric, muscle tone and strength normal, gait normal, no tremors.."]
[textarea cols=60 rows=2 default="SKIN: warm, well perfused, no rashes or birth marks, _acanthosis."]
[textarea cols=60 rows=2 default="GU: normal female, no enlarged clitoris. _normal male, testes (Rt: _ml, Lt:_ml. SPL:_cm)."]
[comment memo="fill out"]
Tanner stage:
-T[select value="1|2|3|4|5"] pubic hair
-T[select value="1|2|3|4|5"] [select value="breast|testes"]
[checklist value=" lipohypertrophy at injection/infusion sites"][comment memo="fill out"]Growth parameters:
-Current height Z score: [textarea cols=5 rows=1 default="_"]
-Current weight Z score: [textarea cols=5 rows=1 default="_"]
-Current BMI Z score: [textarea cols=5 rows=1 default="_"]
[textarea cols=60 rows=1 default="-Weight _ percentile, BMI _percentile"]
-Growth velocity:[textarea cols=60 rows=1 default=" _ cm/yr in the last _"]
[textarea cols=60 rows=1 default="-Growth curve description: patient growth following percentiles "]
___________________________________
IMPRESSION:
[comment memo="fill out"][textarea cols=60 rows=2 default="1. Type 1 diabetes (diagnosed on _ , on MDI insulin regimen with iCGM, _ controlled, A1c _%). "]
-[select value="Excellent|Good|Fair|Poor"] glycemic control.
-[select value="Excellent|Good|Fair|Poor"] diabetes self-management care.
-[select value="Excellent|Good|Fair|Poor"] family involvement in the care of diabetes.
[textarea default="_"]
[textarea cols=60 rows=2 default="2. Growth, normal."]
PLAN:[comment memo="skip"]
1. [textarea default="Adjust insulin regimen doses _"]
2. [textarea cols=60 rows=2 default="Labs/investigations:
- DM routine monitoring labs per ADA guidelines"]
[checklist value="TSH/FT4|Thyroid antibodies|celiac screening tTG-IgA|lipid panel|urine A/C ratio|vitamin D/CMP|A1C|retinopathy"]
3. Counseling: diabetes glycemic goals, self-care management.
4. Diabetes multidisciplinary team assessment for today:
[checklist value="Diabetes Educator|Dietitian|Psychologist"]
5. Referral: [textarea cols=8 rows=1 default="none."]
6. Follow up: [textarea cols=20 rows=1 default="in 3-4 months with me."]
___________________________________
Routine monitoring/ surveillance for T1D based on ADA 2022 guidelines:
1. Hypoglycemia assessment [q 3 mo visit] == [select value="done|deferred"] [date]. [textarea cols=20 rows=1 default="(no hypoglycemia)"]
2. Psychosocial assessment [q 3 mo visit] == [select value="done by physician|deferred"] [date]. [textarea cols=20 rows=1 default="(no concerns)"]
3. Growth and puberty [q 3 mo visit] == [select value="done|deferred"] [date]. [textarea cols=20 rows=2 default="(normal growth, _Tanner )"]
4. BP [q 3 mo visit] == [select value="done|deferred"] [date]. [textarea cols=20 rows=1 default="(normal)"]
5. Foot exam [done annually if age >=10 years (or onset of puberty, if earlier) + diabetes for >=5 years] == [select value="not indicated|done"] [textarea cols=20 rows=1 default="_, (normal)"]
6. urine A/C ration [done annually if age >=10 years (or onset of puberty, if earlier) + diabetes for >=5 years] == [select value="not indicated|done"] [textarea cols=20 rows=1 default="_, (normal)"]
7. A1C level [q 3 mo visit] == [date]. [textarea cols=20 rows=1 default="(%)"]
8. lipid profile [done at diagnosis once glycemic control is acheived and age >=2yr. If initial LDL =100, initiate serial testing at age 9-11 years and --> repeat q3 yrs if normal. repeat annually if LDL is abnormal or if glycemic control is poor.] == [select value="done|ordered"] [date]. [textarea cols=20 rows=1 default="(unremarkable)"]
9. thyroid profile [done at diagnosis, then q1-2yrs . ADA suggests that antibodies to TPO and thyroglobulin should be measured at diagnosis.] == [select value="done|ordered"] [date]. [textarea cols=20 rows=1 default="(unremarkable, antibodies _)"]
10. celiac screening (IgA, tTG) [ at diagnosis. Repeat within 2 yrs of dx, then after 5 years, or if GI develop, and more frequently if a first-degree relative has celiac disease] == [select value="done|ordered"] [date]. [textarea cols=20 rows=1 default="(_normal IgA, tTG _)"]
11. retinopathy screening [Done q2hyrs starting at age >=11 years (or onset of puberty, if earlier) + diabetes for 3 -5 years] == [select value="not indicated|done|ordered"] [textarea cols=20 rows=1 default="_, (normal)"]
___________________________________
Counseling:
I have counseled the family extensively on diabetes pathophysiology, importance of adherence to diabetes care, avoidable complications and intensive management strategies, and diabetes management plan outlined above.
fill out
Pediatric Diabetes Clinic Note
Consultant:
Date: (M-D-Y)
Patient accompanied by:
fill out
___________________________________
Chief Complaint/Reason for visit:
In Summary:
This is a , with . was diagnosed on .
Problem list:
1. Diabetes,
.The patient .
may skip text
___________________________________
HPI:
-Family diabetes concerns today are:
.
ROS:fillout

Puberty:will disappear ___________________________________
INSULIN THERAPY:fillout
-Basal insulin () = units
-Bolus insulin () = ISF: , Target 100 mg/dL.
-TDD = units/kg/day (% basal, %bolus)

[+] Insulin injections are given by .
fillout
GLYCEMIC CONTROL: fillout
TAR %
TIR %
TBR %
Sensor use % for
GMI:
Interpretation: .
last DKA _ (on diagnosis)"]
DIET: fillout

EXERCISE: fillout

PSYCHOSOCIAL:fillout
[x] Lives with .
[x] Diabetes primarycare giver is .
[x] Education/Work structure: .
[x] School: Grade.

Challenges are: will disappear
FAMILY HX
-
DIABETES CARE ASSESSMENT:fillout
- adherence to blood glucose monitoring and insulin administration.
- diabetes control.
-
___________________________________
PHYSICAL EXAM .









fill out
Tanner stage:
-T pubic hair
-T
fill outGrowth parameters:
-Current height Z score:
-Current weight Z score:
-Current BMI Z score:

-Growth velocity:

___________________________________
IMPRESSION:
fill out
- glycemic control.
- diabetes self-management care.
- family involvement in the care of diabetes.


PLAN:skip
1.
2.

3. Counseling: diabetes glycemic goals, self-care management.
4. Diabetes multidisciplinary team assessment for today:

5. Referral:
6. Follow up:
___________________________________
Routine monitoring/ surveillance for T1D based on ADA 2022 guidelines:
1. Hypoglycemia assessment [q 3 mo visit] == .
2. Psychosocial assessment [q 3 mo visit] == .
3. Growth and puberty [q 3 mo visit] == .
4. BP [q 3 mo visit] == .
5. Foot exam [done annually if age >=10 years (or onset of puberty, if earlier) + diabetes for >=5 years] ==
6. urine A/C ration [done annually if age >=10 years (or onset of puberty, if earlier) + diabetes for >=5 years] ==
7. A1C level [q 3 mo visit] == .
8. lipid profile [done at diagnosis once glycemic control is acheived and age >=2yr. If initial LDL =100, initiate serial testing at age 9-11 years and --> repeat q3 yrs if normal. repeat annually if LDL is abnormal or if glycemic control is poor.] == .
9. thyroid profile [done at diagnosis, then q1-2yrs . ADA suggests that antibodies to TPO and thyroglobulin should be measured at diagnosis.] == .
10. celiac screening (IgA, tTG) [ at diagnosis. Repeat within 2 yrs of dx, then after 5 years, or if GI develop, and more frequently if a first-degree relative has celiac disease] == .
11. retinopathy screening [Done q2hyrs starting at age >=11 years (or onset of puberty, if earlier) + diabetes for 3 -5 years] ==
___________________________________
Counseling:
I have counseled the family extensively on diabetes pathophysiology, importance of adherence to diabetes care, avoidable complications and intensive management strategies, and diabetes management plan outlined above.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.44, 138 form elements, 384 boilerplate words, 1 text boxes, 65 text areas, 9 dates, 2 checkboxes, 11 check lists, 30 drop downs, 17 comments, 3 conditionals, 166 total clicks
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