What should be included in a short progress note for a patient with diabetes?

Diabetes Short Progress Note Template

A diabetes progress note should systematically document glycemic control metrics, medication adherence, complications screening, and lifestyle factors, following the structured approach outlined by the American Diabetes Association. 1, 2

Subjective (History of Present Illness)

Glycemic Control Assessment

• Blood glucose monitoring results: Document patterns of hyperglycemia or hypoglycemia, including frequency, severity, and timing of any hypoglycemic episodes 1, 2
• Technology data review: CGM data trends, insulin pump settings, connected pen data, or glucose meter downloads 2
• Hypoglycemia awareness status: Assess whether patient recognizes low blood glucose symptoms 1

Medication Management

• Current diabetes medications: List all agents with doses and adherence patterns 1
• Medication adherence barriers: Document any medication rationing, side effects, or obstacles to taking medications as prescribed 2
• Recent medication changes: Note any adjustments since last visit 2

Lifestyle Factors

• Eating patterns: Current meal plan adherence, carbohydrate counting familiarity, weight changes 1, 2
• Physical activity: Current exercise patterns and frequency 1, 2
• Tobacco, alcohol, substance use: Document current use 2

Complications Screening Symptoms

• Microvascular symptoms: Vision changes, numbness/tingling in extremities, foot problems, sexual dysfunction 1, 2
• Macrovascular symptoms: Chest pain, shortness of breath, claudication 2
• Autonomic symptoms: Orthostatic dizziness, gastroparesis symptoms, changes in bowel/bladder habits 2

Psychosocial Assessment

• Mental health screening: Depression, anxiety, diabetes distress, fear of hypoglycemia 1, 2
• Cognitive function: Especially in older adults 2

Objective (Physical Examination)

Vital Signs and Anthropometrics

• Height, weight, BMI: Compare to previous values 1, 2
• Blood pressure: Include orthostatic measurements when indicated 1, 2

Focused Examination

• Cardiovascular: Heart rate/rhythm, murmurs, peripheral pulses, signs of heart failure 2
• Comprehensive foot examination: Visual inspection, pedal pulses, monofilament testing, vibration sense, ankle reflexes 1, 2
• Skin inspection: Injection sites for lipodystrophy, acanthosis nigricans 1, 2
• Neurological: Sensory deficits in lower extremities, deep tendon reflexes, proprioception 2
• Thyroid palpation: Especially for type 1 diabetes 1, 2

Assessment (Laboratory Evaluation)

Required Testing

• A1C: If results not available within past 2-3 months 1

Annual Testing (if not performed within past year)

• Fasting lipid profile: Total cholesterol, LDL, HDL, triglycerides 1
• Renal function: Spot urine albumin-to-creatinine ratio, serum creatinine, calculated GFR 1
• Liver function tests 1
• TSH: For type 1 diabetes, dyslipidemia, or women over age 50 1

Plan

Medication Adjustments

• Document any changes to diabetes medications, insulin doses, or other therapies based on glycemic control 1

Self-Management Education

• SMBG frequency: Three or more times daily for patients on multiple insulin injections or pump therapy; less frequent for those on non-insulin therapies 1
• CGM consideration: For adults ≥25 years with type 1 diabetes on intensive insulin regimens 1

Lifestyle Recommendations

• Physical activity: 150 minutes/week of moderate-intensity aerobic activity spread over at least 3 days, plus resistance training 2-3 sessions/week 1
• Nutrition counseling: Referral to registered dietitian if needed 1

Referrals and Follow-up

• Eye care professional: Annual dilated eye exam 1
• Diabetes self-management education (DSME): As needed 1
• Mental health professional: If psychosocial concerns identified 1
• Dentist: Comprehensive periodontal examination 1

Vaccination Status

• Review and update as needed 2

Next Appointment

• Schedule follow-up based on glycemic control and treatment complexity 1

Critical Pitfalls to Avoid

• Neglecting comprehensive foot examination: This is essential to prevent diabetic foot complications 2
• Omitting psychosocial screening: Depression and diabetes distress significantly impact self-management and outcomes 1, 2
• Forgetting vaccination status assessment: Leaves patients vulnerable to preventable infections 2
• Failing to review actual glucose data: Don't rely solely on A1C; review patterns from meters, CGM, or logs 1, 2