Diabetes Educators Calgary Charting Guidelines

Intake (pilot)

Intake Appointment (pilot)

 

Standard Tab Layout

Standard Tab Layout

Process

Check schedule

  1. The schedule is under the department "CGY SMG Diabetes Educators".
  2. Open patient chart.
  3. Under Chart Review tab, look at referral (either 'Referrals' or 'Media' sub-tab).
  4. Start visit only after reaching patient. Click "Start the Visit", then "Check In" on the Appts tab.
    1. If you do not reach the patient, mark as No Show (at top of schedule view). Use 'Telephone Call' to document attempt to contact and send note to referring provider.

Demographics

  1. Click on name in Storyboard to verify name, DOB, email, language and need for interpreter.
  2. Verify PCP (primary care provider). Again, click the PCP in storyboard.

Agenda

  1. If not continuing:. 
    1. Document in note and send to referring provider.
    2. No further appointments are booked.
    3. Keep a tally. 
  2. If continuing, start the Episode of Care.
    Name = DCC
    Type = Diabetes Chronic Disease Management
  3. Document patient expectations in note (Smart Phrase: DCCCINTAKE)

Safety

  1. Use the 'Diabetes Management' tab, and the Smart List in the Safety section of the Smart Phrase DCCCINTAKE.
  2. Use judgment:  If you feel that psychosocial services should be requested, after your main note is completed, use the Smart Phrase: DCCCPSYCHSWCONSULT. Fax to 403-476-9626. 

Health information

  1. Document the type of diabetes under "Chart Review" tab > Problem List. [It’s important to be accurate. Use a more general Medical Problem, e.g. “Diabetes” if the type of diabetes is uncertain.]
  2. Click "Add Dx" at bottom of chart and pick from the list of Problems.
  3. Medications: Click link under Chart Review tab. If the patient is on insulin and it is not already listed, see this link for how to chart types and doses.
  4. Height/weight: Documented in Flowsheets > Vitals. Method = Stated
  5. Glucose readings: Document under the ‘Diabetes Management’ tab. Indicate these are verbally reported: e.g. 9 – 10 verbal]
  6. Complications: Use the Smart List within the Smart Phrase to document these
  7. Health maintenance items:
    1. Foot exam: Documented by clicking on Care Gaps in Storyboard.
    2. Eye exam: Documented by clicking on Care Gaps in Storyboard.
    3. COVID vaccine: Documented by using the Smart List within the Smart Phrase.
    4. Flu vaccine: Documented by using the Smart List within the Smart Phrase.
    5. Pneumococcal vaccine: Documented by using the Smart List within the Smart Phrase. 

Appointment Preparation

No specific documentation required. The Smart Phrase covers this.

Book Appointment

  1. Go to Appts tab > Make Appt
  2. Department = CGY SMG Diabetes Educators. Visit Type = Virtual Home/Community New.
    1. If urgent (Uncontrolled, symptomatic diabetes with fasting/ac BG >18-20 mmol/L and/or ketones >1.5), book the first available appointment with any RN or RD (within 24-72 hours). 90 minutes
    2. If needing a soon appointment (New to insulin, hospital discharge, or diabetes medication adjustment secondary to steroids and glucose readings) book within 5 days. 90 minutes
    3. If needing to be booked with Diabetes in Pregnancy (pregnant or planning pregnancy within 6 months): send referral immediately to SMG DIP
    4. Otherwise, it’s routine: book 60 minutes 2-3 weeks out for an RN or RD assessment then book another appointment 5-10 days after that one for the other profession (RD or RN). 

 

The Appointment – What to prepare

No specific documentation required. The Smart Phrase covers this.

Send email to patient. Subject line = “Per our discussion”. Send the following link: https://cumming.ucalgary.ca/resources/endocrinology-metabolism/patients-and-family/diabetes/appointment-preparation

 

Send Communication and Sign Visit