What is an example of a History of assessment in SOAP for a patient with diabetes?

Example of a History Assessment in SOAP for a Patient with Diabetes

A comprehensive history assessment for a diabetic patient should include specific details about glycemic control, complications, and self-management behaviors to guide treatment decisions and improve outcomes.

Key Components of Diabetes History Assessment

Diabetes History

• Characteristics at diabetes onset (age, symptoms at diagnosis) 1
• Type of diabetes (type 1, type 2, gestational, other)
• Duration of diabetes
• Review of previous treatment regimens and response to therapy 1
• A1C history and trends 1
• Frequency, severity, and causes of past hospitalizations (DKA, hyperosmolar state) 1

Glycemic Control Assessment

• Blood glucose monitoring patterns:
  • Self-monitoring blood glucose (SMBG) frequency and timing 1
  • Review of glucose logs or downloaded meter/CGM data 1
  • Pattern of hyperglycemia (fasting, postprandial, overnight) 1
  • Patient's understanding and use of glucose data for self-management 1
• Hypoglycemia assessment:
  • Frequency, severity, timing, and causes of hypoglycemic episodes 1
  • Hypoglycemia awareness/unawareness 1
  • Severe hypoglycemia events requiring assistance 1

Medication History

• Current medication regimen (insulin, oral agents, non-insulin injectables) 1
• Medication adherence patterns 1
• Medication side effects or intolerances 1
• Insulin administration technique (if applicable)
• For patients on insulin: dosing schedule, carbohydrate ratios, correction factors 2

Diabetes Self-Management

• Eating patterns and nutritional status 1
  • Meal timing and consistency
  • Carbohydrate counting knowledge (for those on insulin) 1
  • Dietary restrictions or preferences
• Physical activity patterns 1
  • Type, frequency, duration of exercise
  • Exercise-related hypoglycemia
• Weight history and BMI trends 1
• Sleep patterns and quality 1
• Technology use (pumps, CGM, apps) 1

Complications and Comorbidities

• Microvascular complications:
  • Retinopathy: last eye exam, vision changes 1
  • Nephropathy: kidney function, proteinuria 1
  • Neuropathy: numbness, tingling, pain, autonomic symptoms 1
• Macrovascular complications:
  • Cardiovascular disease history
  • Cerebrovascular disease
  • Peripheral arterial disease 1
• Common comorbidities:
  • Hypertension 1
  • Dyslipidemia 1
  • Obesity
  • Thyroid disorders 1
  • Depression/anxiety 1

Preventive Care

• Immunization status (influenza, pneumococcal, hepatitis B) 1
• Foot care practices and history of foot problems 1
• Last dental visit 1
• Last dilated eye examination 1
• Last comprehensive foot examination 1

Social and Behavioral Factors

• Tobacco, alcohol, and substance use 1
• Diabetes education history 1
• Social determinants of health (food security, housing, transportation) 1
• Family/social support system 1
• Occupation and work schedule (impact on diabetes management)
• Stress levels and coping mechanisms

Documentation Example

S: 56-year-old male with 8-year history of type 2 diabetes presents for follow-up. Reports average home blood glucose readings of 180-220 mg/dL fasting and 200-250 mg/dL postprandial over past month. Checks glucose 1-2 times daily, usually before breakfast. Reports one episode of hypoglycemia (62 mg/dL) last month after missing lunch. Taking metformin 1000mg BID and glipizide 10mg daily before breakfast but admits missing evening metformin dose 2-3 times weekly due to GI discomfort. Last A1C was 8.7% three months ago. Reports numbness and tingling in both feet that has worsened over past 6 months, particularly at night. Denies polyuria, polydipsia, or vision changes. Walking 15 minutes 3 times weekly but finds it increasingly difficult due to foot discomfort. Diet consists of 3 meals daily with frequent high-carbohydrate snacks in evening. Last eye exam 18 months ago, last dental visit >2 years ago. Received flu vaccine this season but pneumococcal vaccination status unknown. Works night shift as security guard 4 days weekly. Reports increased stress due to financial concerns affecting medication adherence.

Common Pitfalls to Avoid

• Failing to document specific glucose patterns and variability
• Not assessing hypoglycemia risk and awareness
• Overlooking medication adherence issues
• Neglecting to evaluate diabetes self-management skills
• Missing social determinants that impact diabetes care
• Incomplete assessment of complications screening status
• Not documenting patient's understanding of their condition

By following this structured approach to history assessment, healthcare providers can better identify areas needing intervention and develop targeted treatment plans to improve outcomes for patients with diabetes.