What should be included in a clinical progress admission note for an adult patient with a history of diabetes or hypertension at a hospital on a given date?

Clinical Progress Admission Note Template for Adult Patient with Diabetes/Hypertension

A comprehensive admission note for an adult patient with diabetes or hypertension should clearly document the diabetes type in the medical record, obtain an A1C if not performed in the prior 3 months, and establish a structured insulin regimen that avoids sliding scale insulin as monotherapy. 1

Patient Identification and Chief Complaint

• Document patient name, medical record number, date of birth, admission date, and location 1
• State primary reason for admission with brief description of presenting symptoms 1

History of Present Illness

• Diabetes-specific elements: Document characteristics at onset (age, symptoms), review of previous treatment regimens and response, frequency/cause/severity of past hospitalizations related to diabetes 1
• Hypoglycemia history: Assess awareness, frequency, causes, and timing of episodes 1
• Recent glycemic control: Changes in blood glucose patterns, medication adherence, and any precipitating factors for current admission 1
• Hypertension history: Duration, previous blood pressure readings, medication compliance, and any hypertensive complications 2

Past Medical History

• Clearly identify diabetes type (type 1 or type 2) in the medical record 1
• Document common comorbidities: obesity, obstructive sleep apnea, nonalcoholic fatty liver disease 1
• History of high blood pressure or abnormal lipids 1
• Macrovascular complications: Coronary artery disease, myocardial infarction, stroke, congestive heart failure, peripheral vascular disease 2
• Microvascular complications: Retinopathy, nephropathy, neuropathy 1, 2
• Presence of hemoglobinopathies or anemias 1

Medications

• Current medication regimen with doses and frequencies 1
• Medication-taking behavior and adherence patterns 1
• Medication intolerance or side effects 1
• Complementary and alternative medicine use 1

Social History

• Social determinants of health: Food security, housing stability, transportation access, financial security, community safety 1
• Identify existing social supports and surrogate decision maker 1
• Tobacco, alcohol, and substance use 1
• Physical activity and sleep behaviors 1
• Eating patterns and weight history 1

Family History

• Family history of diabetes in first-degree relatives 1
• Family history of autoimmune disorders 1
• Family history of cardiovascular disease 2

Review of Systems

• Screen for depression, anxiety, and disordered eating 1
• Last dental visit and last dilated eye examination 1

Physical Examination

• Vital signs: Height, weight, BMI, blood pressure (including orthostatic measurements when indicated) 1
• Fundoscopic examination (or document referral to eye specialist) 1
• Thyroid palpation 1
• Skin examination: Acanthosis nigricans, insulin injection or insertion sites, lipodystrophy 1
• Comprehensive foot examination: Visual inspection for skin integrity, callous formation, foot deformity or ulcer, toenails; screen for peripheral arterial disease with pedal pulses (refer for ankle-brachial index if diminished); determination of temperature, vibration or pinprick sensation, and 10-g monofilament exam 1

Laboratory and Diagnostic Studies on Admission

• A1C: Perform on all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL) if not performed in prior 3 months 1
• Basic metabolic panel to assess renal function and electrolytes 1
• Complete blood count 1
• Lipid panel if not recently obtained 1
• Urinalysis 1
• Consider troponin levels given high prevalence of coronary artery disease in patients with diabetes and hypertension 1

Assessment and Plan

Diabetes Management

• Avoid sliding scale insulin as monotherapy - this practice is strongly discouraged 1

For noncritically ill patients:

• Target premeal blood glucose <140 mg/dL with random blood glucose <180 mg/dL 1
• For patients with poor oral intake or NPO status: Implement basal plus correction insulin regimen 1
• For patients with good nutritional intake: Implement insulin regimen with basal, nutritional, and correction components 1
• Use validated written or computerized insulin protocols that allow predefined adjustments based on glycemic fluctuations 1

For critically ill patients:

• Initiate insulin therapy for persistent hyperglycemia at threshold ≤180 mg/dL 1
• Target glucose range of 140-180 mg/dL for majority of critically ill patients 1
• Use intravenous insulin protocol with demonstrated efficacy and safety 1

Hypoglycemia Prevention

• Establish hypoglycemia management protocol and prevention plan for this patient 1
• Document any hypoglycemic episodes in medical record 1

Hypertension Management

• Continue oral antihypertensive therapy for most patients, especially those with concomitant hypertension 1
• Consider reduction or temporary discontinuation of ACE inhibitors, ARBs, and/or aldosterone antagonists only if worsening azotemia develops 1
• Monitor blood pressure regularly during hospitalization 1

Vaccination Status

• Review vaccination history and provide routinely recommended vaccinations according to age-appropriate recommendations 1

Discharge Planning

• Begin discharge planning at admission with clear diabetes management instructions to be provided at discharge 1
• For patients with A1C <7.5-8%: Consider discharge on prehospitalization treatment regimen 1
• For patients with A1C 8-10%: Consider discharge on oral agents plus basal insulin at 50% of hospital basal dose 1
• For patients with A1C >10%: Discharge on basal-bolus regimen or combination of preadmission oral agents plus 80% of hospital basal insulin dose 1
• Arrange diabetes self-management education including medication administration, glucose monitoring, and hypoglycemia recognition and treatment 1

Follow-up

• Document follow-up appointments with primary care physician and endocrinology if indicated 1
• Ensure appropriate testing and care documented at discharge for patients with new hyperglycemia diagnosis 1