Diabetes Follow-Up Template for [PATIENT]
Visit Frequency
Schedule follow-up visits every 3-6 months for patients with stable glycemic control, with mandatory annual comprehensive evaluations for all diabetic patients. 1, 2 Increase visit frequency to every 1-2 weeks to 3 months for patients with poor glycemic control, recent medication changes, or active complications. 1, 2
Every 3-6 Month Visit Components
Vital Signs and Anthropometrics
- Measure height, weight, and calculate BMI to track weight trends and assess obesity management 1, 2
- Check blood pressure at every visit as part of cardiovascular risk assessment 1, 2
Laboratory Testing
- Perform A1C testing if results are not available within the past 3 months 1, 2
- Monitor A1C every 3 months until glycemic targets are achieved, then at least twice yearly once stable 1, 2
- Target A1C <7% for most adults, with more stringent targets (<6.5%) for selected individuals without significant hypoglycemia risk 1, 3
Clinical Assessment
- Review self-management behaviors: nutrition adherence, medication compliance, physical activity patterns, and blood glucose monitoring 1, 2
- Assess hypoglycemia and hyperglycemia episodes: frequency, severity, precipitating factors, and patient's ability to recognize and treat 1, 2
- Screen for depression, anxiety, and disordered eating at every visit, as these conditions are highly prevalent and bidirectionally related to diabetes control 1, 2
- Review diabetes self-management education needs and problem-solving skills 1, 2
Annual Comprehensive Evaluation
Laboratory Panel
- Lipid profile (total, LDL, HDL cholesterol, and triglycerides) 1, 2
- Spot urinary albumin-to-creatinine ratio for nephropathy screening 1, 2
- Serum creatinine and estimated glomerular filtration rate 1, 2
- Liver function tests 1, 2
- Thyroid-stimulating hormone in people with type 1 diabetes 1, 2
- Vitamin B12 if patient is on metformin 1, 2
- Serum potassium levels in patients on ACE inhibitors, ARBs, or diuretics 1, 2
Comprehensive Foot Examination
- Visual inspection for skin integrity, callous formation, deformities, or ulcers 1, 2
- Peripheral arterial disease screening by checking pedal pulses; refer for ankle-brachial index if pulses are diminished 1, 2
- Assessment of temperature, vibration or pinprick sensation, and 10-g monofilament examination 1
- Evaluate for neuropathy using 128-Hz tuning fork, pinprick sensation, or ankle reflexes 4
Physical Examination
- Skin examination for acanthosis nigricans, insulin injection sites, and lipodystrophy 1
- Thyroid palpation 1
Ophthalmologic Follow-Up
- Type 1 diabetes patients: Initial dilated comprehensive eye examination within 3-5 years after diabetes onset 1, 4
- Type 2 diabetes patients: Initial examination shortly after diagnosis 1, 4
- Subsequent examinations annually for both type 1 and type 2 diabetes patients 1, 4
- More frequent examinations required if retinopathy is progressing 1, 4
- Prompt referral to ophthalmologist for severe nonproliferative diabetic retinopathy, any proliferative diabetic retinopathy, or macular edema 1, 4
Vaccination and Preventive Care
- Annual influenza vaccine for all diabetic patients 1, 2
- Pneumococcal vaccines (PPSV23 and PCV13) according to CDC schedules 1, 2
- Hepatitis B vaccination for unvaccinated adults with diabetes aged 19-59 years 1, 2
- COVID-19 vaccines per current CDC recommendations 1
Psychosocial and Lifestyle Assessment
- Assess diabetes self-management behaviors at each visit, including problem-solving skills for all aspects of diabetes management 1, 2
- Screen for depression, anxiety, disordered eating, and cognitive impairment, particularly when self-management is poor 1, 2
- Evaluate sleep patterns and duration, as poor sleep quality and abnormal sleep duration are associated with higher A1C 1
- Assess social determinants of health that may impact diabetes management 1, 2
Diabetes Self-Management Education
- Provide ongoing diabetes self-management education and support throughout the course of care, not just at diagnosis 1, 2
- Include problem-solving skills for all aspects of diabetes management by qualified diabetes educators 1, 3
- Smoking cessation counseling as routine component for all tobacco users 2
Post-Hospitalization Follow-Up
Schedule outpatient follow-up within 1 month of discharge for patients who experienced hyperglycemia or hypoglycemia during hospitalization. 4, 1, 2 Earlier appointments (1-2 weeks) are preferred if glycemic management medications were changed or glucose control was suboptimal at discharge. 4, 1, 2
Discharge Planning Components
- Identify the healthcare provider who will provide diabetes care after discharge 4
- Review level of understanding related to diabetes diagnosis, glucose monitoring, home glucose goals, and when to call a healthcare professional 4
- Educate on recognition, treatment, and prevention of hyperglycemia and hypoglycemia 4
- Provide information on healthy food choices and referral to registered dietitian nutritionist if needed 4
- Review medication administration, including insulin and noninsulin injectables 4
- Discuss sick-day management 4
- Ensure proper use and disposal of diabetes supplies (insulin pens, pen needles, syringes, glucose meters, lancets) 4
- Provide appropriate durable medical equipment, medications, and prescriptions at discharge to avoid dangerous hiatus in care 4
Common Pitfalls to Avoid
- Do not overlook psychosocial screening, as diabetes-related distress affects 18-45% of patients and significantly impacts self-management 2
- Do not forget medication reconciliation at every transition of care to ensure no chronic medications are stopped and new prescriptions are safe 4, 2
- Do not delay ophthalmologic referral for patients with severe retinopathy or macular edema 1, 4
- Do not skip foot examinations, as early detection of neuropathy and peripheral arterial disease prevents ulcers and amputations 1, 2