**DIABETES PATIENT CARE SUMMARY**

DIABETES PATIENT CARE SUMMARY Report Date: May 04, 2002

Age: 52 Sex: F Date of DM Onset: Jun 1966 (Diabetes Register)

Dob: Jan 01, 1950 DM Problem #: SE1

Primary Care Provider: CURTIS,CLAYTON

Last Height: 63 inches Dec 09, 1998

Last Weight: 188 lbs Jul 07, 1999 BMI: 34.9

Tobacco Use: YES, USES TOBACCO

HTN Diagnosed: Yes

ON ACE Inhibitor/ARB in past 6 months: No

Aspirin Use (in past yr): No

Last 3 BP: 140/90 Jul 07, 1999

150/95 Jun 28, 1999

140/90 Jun 27, 1999

In past 12 months:

Diabetic Foot Exam: No Apr 10, 2000

Diabetic Eye Exam: No Sep 12, 1999

Dental Exam: Yes May 11, 2000 (Dental Exam 30 recorded)

(Females Only)

Pap Smear: Date of Last Pap in PCC: Oct 09, 1998

WH Cervical TX Need: Colposcopy (by 05/15/98)

Mammogram: May 24, 1999 Clinical Breast Exam (by 04/30/98)

Self Monitoring of Blood Glucose: No Strips Dispensed through Pharmacy

DM Education Provided (in past yr):

Last Dietitian Visit: May 05, 1996 DIABETES MELLITUS NUTRITIONAL
ASSESSMEN

DM-NUTRITION Mar 18, 2002

In the past year, the patient has refused the following Diabetes
education:

DM-NUTRITION Jul 16, 2001

Immunizations:

Flu vaccine since August 1st: No May 11, 2000

Pneumovax ever: Yes Apr 22, 1994

Td in past 10 yrs: Yes Jun 27, 1999

Last Documented PPD: Jul 29, 1999

Last TB Status Health Factor:

EKG May 23, 2000

Laboratory Results (most recent):

HbA1c: 8.4 Jul 16, 2001

Next most recent HbA1c: 4.4 Jun 01, 2001

Nephropathy Assessment

Urine Protein: 100 Jul 16, 2001

Microalbuminuria:

Creatinine: 1.4 Mar 11, 2000

Total Cholesterol: 66 Oct 27, 2000 Refused-02/24/00

LDL Cholesterol: 140 Nov 01, 2000 Refused-02/24/00

HDL Cholesterol: 66 Oct 27, 2000

Triglycerides: 300 Dec 05, 2000

# Resource and Patient Management System (RPMS) Diabetes Patient Care Summary from the Indian Health Service [www.ihs.gov/Cio/RPMS/index.asp](http://www.ihs.gov/Cio/RPMS/index.asp) 

**INDIVIDUAL DM AUDIT**

AUDIT DATE: Apr 01, 2002 FACILITY NAME: SELLS HOSPITAL

AREA: 00 SU: 01 FACILITY: 01 \# PTS ON DM REGISTER: 130

TRIBAL AFFIL: 096 TOHONO O\'ODHAM NATIO COMMUNITY: 0410034 SANTA ROSA

REVIEWER: DKR CHART #: 100010 DOB: Jan 01, 1950 SEX: FEMALE

PRIMARY CARE PROVIDER: CURTIS,CLAYTON

DATE OF DIABETES DIAGNOSIS: IMMUNIZATIONS

CMS Register: Jun 1966 Flu vaccine (past yr): No

Problem List: Nov 1979 Pneumovax Ever: Yes - Apr 22, 1994

1st DX recorded in PCC: Jul 26, 1992 Td in past 10 yrs: Yes - Jun 27,
1999

Diabetes Type: 2 Type 2 PPD Status: POS

CMS Register: TYPE 2 If PPD Pos, INH Tx Complete:

Problem List: 250.00;250.81;250.80

PCC POV\'s: Type 2 If PPD Neg, Last PPD date:

TOBACCO USE: 1 Current User Date of Last EKG: May 23, 2000

Referred for (or provided)

cessation counseling: No LABORATORY DATA

HbA1c (most recent): 8.4

VITAL STATISTICS Date Obtained: Jul 16, 2001

Height: 63 inches Dec 09, 1998 HbA1c (next most recent): 4.4

Last Weight: 188 lbs Jul 07, 1999 Date Obtained: Jun 01, 2001

HTN (documented DX): Yes Last 3 Blood Sugars (in past yr)

Last 3 Blood Pressures (in past yr):

MOST RECENT SERUM VALUE (in the

past 12 months):

EXAMINATIONS (in past year) Creatinine:

Foot exam-complete: Total Cholesterol:

No HDL Cholesterol:

Eye exam (dilated/fundus): LDL Cholesterol:

No Triglycerides:

Dental exam: Urinalysis: Yes 7/16/2001

Refused Proteinuria: Yes 100 7/16/2001

EDUCATION (in past year) Microalbum:

Diet Instruction: Yes (Non RD)

Exercise Instruction: No Self monitoring of blood glucose

DM Education (Other): No documented in chart: No

DM THERAPY Is patient participating in SDM? Yes

Select all that currently apply

X 1 Diet & Exercise Alone

2 Insulin

3 Sulfonylurea Last AST date:

4 Metformin Last ALT:

5 Acarbose

6 Glitazones Pap Smear in past yr: No

9 Unknown/Refused Mammogram in past yr: No

ACE Inhibitor Use: No

Daily Aspirin Therapy: No BMI:

# Resource and Patient Management System (RPMS) Individual DM Audit sheet from Indian Health Service

[www.ihs.gov/Cio/RPMS/index.asp](http://www.ihs.gov/Cio/RPMS/index.asp)