Diabetes F/U

Patient presents to clinic to follow up on Diabetes care. [text]. 
FBG [text]. HgA1c [text]. Previous HgA1c [text].
Medication: [text]
Patient is [select value= compliant|non-comlpiant] with medication
Dietary changes: [text]
Lifestyle changes: [text]
Last diabetic foot exam:[text] ***due***
Last diabetic eye exam [text] ***due***
[textarea default="sample text"]

[select value= admits|denies] blurry vision/changes in vision
[select value= admits|denies] polyuria
[select value= admits|denies]numbness/tingling [text]
[select value= admits|denies]chest pain
[select value= admits|denies]palpitations
[select value= admits|denies]SOB
[select value= admits|denies]LE edema 
[select value= admits|denies]claudication
[select value= admits|denies]gastroparesis
Current medications [text]
PMH: [text]

[OBJECTIVE:
Vitals
General: WDWN, NAD [text]
HEENT: optic disc clear with sharp margins [text]
Heart: RRR, no murmurs, rubs or gallops [text]
Lungs: CTAB[text]
Neuro: gross sensation to light touch intact at C7/8, L5, S1. Achilles reflex 2+ b/l. [text]
Extremities: [text] ***check feet***

Assessment/Plan
Patient presents to clinic for diabetes follow up [text]
Next lab draw [text]
Continue current medication regimen: [text]
Follow up:[text]
Patient educated on: [text]
[textarea default="sample text"]

Labs: A1c every 3 months until <7% then 2x yearly. Lipid profile yearly, kidney function yearly, microalbuminuria yearly. Eye and foot exam yearly. ABI indicated? 
Patient presents to clinic to follow up on Diabetes care. .
FBG . HgA1c . Previous HgA1c .
Medication:
Patient is with medication
Dietary changes:
Lifestyle changes:
Last diabetic foot exam: ***due***
Last diabetic eye exam ***due***


blurry vision/changes in vision
polyuria
numbness/tingling
chest pain
palpitations
SOB
LE edema
claudication
gastroparesis
Current medications
PMH:

[OBJECTIVE:
Vitals
General: WDWN, NAD
HEENT: optic disc clear with sharp margins
Heart: RRR, no murmurs, rubs or gallops
Lungs: CTAB
Neuro: gross sensation to light touch intact at C7/8, L5, S1. Achilles reflex 2+ b/l.
Extremities: ***check feet***

Assessment/Plan
Patient presents to clinic for diabetes follow up
Next lab draw
Continue current medication regimen:
Follow up:
Patient educated on:


Labs: A1c every 3 months until <7% then 2x yearly. Lipid profile yearly, kidney function yearly, microalbuminuria yearly. Eye and foot exam yearly. ABI indicated?

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.29, 35 form elements, 140 boilerplate words, 23 text boxes, 2 text areas, 10 drop downs, 35 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: