Diabetes Educators Calgary Charting Guidelines
Problem List and Visit Diagnoses
Problem List and Visit Diagnosis
- Check and keep the problem list up-to-date. For example, if the problem list has “Diabetes mellitus” because the type of diabetes was previously unclear, change it to the specific type if it is now clear. When you update the problem, you have the option of updating the original one, rather than adding another. The system will link all the information together.
- In almost every case, there is no need to document Medical history.
- An occasional exception is GPA if not already done by Obstetrics - found under the History tab > Obstetrics.
- If GPA is documented already by OB, do not change it.
- Pick Visit Diagnoses and Medical Problem(s) from the relevant table below.
DCC (Non-pregnant)
| Name | Notes |
|---|---|
| Diabetes mellitus, undetermined | If type of diabetes is uncertain |
| Diabetes mellitus type 1 | Type 1 diabetes |
| Diabetes mellitus type 2 | Type 2 diabetes |
| Post-transplant diabetes mellitus | |
| Diabetes mellitus secondary to pancreatectomy | |
| Drug-induced diabetes mellitus | Diabetes induced as a result of drug or chemical |
| Monogenic diabetes | If you know for certain. If uncertain, use a general classification above. |
| Pre-conception counselling | |
| Counseling for Insulin Pump | Use each time for Visit Diagnosis |
Diabetes in Pregnancy
| Name | Notes |
|---|---|
| Preconception counselling | Type 1 or type 2, preconception |
| Diabetes in Pregnancy | If type of diabetes is uncertain, or other specific type of diabetes |
| Pregnancy complicated by pre-existing type 1 diabetes | Type 1 diabetes, currently pregnant |
| Pregnancy complicated by pre-existing type 2 diabetes | Type 2 diabetes, currently pregnant |
| Gestational diabetes mellitus | Gestational diabetes |
| History of gestational diabetes | GDM in previous pregnancy - not yet diagnosed in current pregnancy |
| Gestational Diabetes Mellitus, Postpartum | Patient had GDM, now seen post-partum |
| Pre-existing type 1 diabetes mellitus during pregnancy, postpartum | |
| Pre-existing type 2 diabetes mellitus during pregnancy, postpartum | |
| Counseling for Insulin Pump | Use each time for Visit Diagnosis |
| Monogenic diabetes | If you are certain about the specific type, you may choose it |