EMR Template for Hypertension with Cardiovascular Disease or Diabetes Comorbidities

Chief Complaint and History of Present Illness

Document current blood pressure readings with dates, including out-of-office measurements if available 1
Record duration of hypertension diagnosis and year of onset 1
Document current antihypertensive medications with doses, adherence patterns, and any reported side effects or intolerances 1
Capture symptoms suggesting hypertensive complications: chest pain, shortness of breath, palpitations, claudication, peripheral edema, headaches, blurred vision, nocturia, hematuria, dizziness 1
For diabetic patients, record diabetes type (Type 1 vs Type 2), year of onset, and current treatment method (none, diet, oral agents with specific names including metformin/sulfonylureas/TZDs, insulin, or combination) 1

Document history of myocardial infarction, heart failure, stroke, transient ischemic attacks with years of occurrence 1
Record history of coronary artery disease procedures or interventions 1
Capture family history of premature cardiovascular disease in parents or siblings, including sudden cardiac death (defined as natural death due to cardiac causes with abrupt loss of consciousness) 1

Smoking status: current smoker, former smoker with cessation date, or never smoker 1
Alcohol consumption categorized as: none, ≤1 drink/week, 2-7 drinks/week, ≥8 drinks/week, or documented alcohol dependency with treatment history 1
Physical activity level: document if meeting ≥150 minutes moderate-intensity aerobic activity per week distributed over ≥3 days 2

Blood pressure measurements: document systolic and diastolic values, pulse rate, rhythm, and character 1
Body mass index and waist circumference 1
Cardiovascular examination: jugular venous pressure, apex beat character, presence of extra heart sounds, basal crackles, peripheral edema 1
Vascular examination: presence of bruits (carotid, abdominal, femoral), radio-femoral delay, peripheral pulses 1
Neck circumference if >40 cm (suggests obstructive sleep apnea risk) 1

Serum creatinine with estimated glomerular filtration rate (eGFR) 1
Serum sodium and potassium levels 1
Fasting glucose or HbA1c (target <7% for most diabetic patients) 1, 2
Lipid profile: total cholesterol, LDL-cholesterol (target <100 mg/dL), HDL-cholesterol, triglycerides 1, 2
Urine albumin-to-creatinine ratio 1
For patients on ACE inhibitors, ARBs, or diuretics: document monitoring schedule of renal function and potassium within first 3 months, then every 6 months if stable 2

Normal BP: <120/80 mmHg - lifestyle modifications only 1
Elevated BP (120-129/<80 mmHg) or Stage 1 HTN (130-139/80-89 mmHg) with low risk: lifestyle modifications for several weeks, then add medications targeting <140/90 mmHg 1
Stage 1 HTN with ≥3 risk factors, organ damage, chronic kidney disease stage 3, or diabetes: immediate drug therapy targeting <140/90 mmHg 1
Stage 2 HTN (≥160/100 mmHg): immediate initiation of two drugs or single-pill combination 1
For diabetic patients: target BP <130/80 mmHg with immediate pharmacologic therapy plus lifestyle modification for BP ≥140/90 mmHg 1, 2

First-line therapy for diabetic patients with albuminuria (≥30 mg/g creatinine): ACE inhibitor or ARB at maximum tolerated dose 1
Recommended drug classes: ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers 1
Contraindicated combinations: ACE inhibitors with ARBs, or either with direct renin inhibitors 1
For resistant hypertension (BP ≥140/90 mmHg despite appropriate lifestyle management plus diuretic and two other antihypertensive drugs): consider mineralocorticoid receptor antagonist 1
Document statin therapy for patients age >40 years with diabetes and ≥1 cardiovascular risk factor, targeting ≥30-40% LDL-C reduction 2
Aspirin 75-162 mg daily for primary prevention in diabetic patients with 10-year cardiovascular risk >10% 2

For heart failure patients: document left ventricular hypertrophy on ECG, ejection fraction if available, New York Heart Association class 1
History of exposure to cardiotoxic agents: anthracyclines (doxorubicin, daunorubicin) with cumulative dose, thoracic radiation with location and total exposure 1
History of thyroid disorder: current thyroid supplementation or treatment for hyperthyroidism 1
Dyslipidemia documentation: total cholesterol >200 mg/dL, LDL ≥130 mg/dL, HDL <35 mg/dL, or current lipid-lowering therapy 1

Blood pressure at every routine visit 2
HbA1c every 3 months until at goal, then at least twice yearly for diabetic patients 2
Lipid panel at least annually 2
Renal function (urine albumin-to-creatinine ratio and eGFR) annually 2
Retinopathy screening annually by ophthalmologist or optometrist for diabetic patients 2
Serum creatinine/eGFR and potassium at least annually for patients on ACE inhibitors, ARBs, or diuretics 1

Blood pressure: <130/80 mmHg for diabetic patients; <140/90 mmHg for non-diabetic hypertensive patients 1, 2
HbA1c: <7% for most patients, individualized toward 6% when achievable without significant hypoglycemia 2
LDL-cholesterol: <100 mg/dL 2

Dietary pattern: DASH-style diet with 8-10 servings fruits/vegetables daily, 2-3 servings low-fat dairy, sodium <2,300 mg/day 1, 2
Alcohol: ≤2 drinks/day for men, ≤1 drink/day for women 1
Weight loss plan if BMI indicates overweight or obesity 1
Exercise prescription: ≥150 minutes moderate-intensity aerobic activity per week, distributed over ≥3 days with no more than 2 consecutive days without activity 2