Documentation of Absence of Diabetes in Consult Notes
Document "no history of diabetes mellitus" or "denies history of diabetes" in the Past Medical History section of your consult note. 1
Recommended Documentation Approach
When documenting that a patient has no prior history of diabetes, use clear, unambiguous language in the Past Medical History section:
- State explicitly: "No history of diabetes mellitus" or "Patient denies history of diabetes" 1
- Alternative phrasing: "Diagnosis of DM or IFG absent" (where IFG = impaired fasting glucose) 1
- For hospital admission orders: Initial orders should state the type of diabetes (type 1, type 2) or explicitly note "no previous history of diabetes" 1
Essential Context to Include
When documenting absence of diabetes, consider adding relevant screening information to strengthen your documentation:
- Document if screening was performed: Note whether you obtained fasting plasma glucose, A1C, or other glycemic testing during the current encounter 1
- Include risk factor assessment: Document presence or absence of diabetes risk factors (obesity, family history, hypertension, cardiovascular disease, physical inactivity) even when diabetes is absent 1, 2
- For cardiac rehabilitation or high-risk patients: Explicitly confirm "presence or absence of diabetes" through medical record review 1
Common Documentation Pitfalls to Avoid
- Don't leave it blank: Absence of documentation does not equal documentation of absence. Explicitly state "no history of diabetes" rather than omitting it 1
- Don't use ambiguous terms: Avoid vague phrases like "non-diabetic" without context, as this could refer to current status versus historical diagnosis 1
- Don't forget to update: If you perform screening tests during the encounter that reveal new diabetes or prediabetes, update your documentation accordingly 1, 2
Structured Documentation Template
For optimal clarity, structure your Past Medical History section as follows:
Past Medical History:
- No history of diabetes mellitus
- [Other relevant conditions]
Or in a problem-oriented format:
- Diabetes mellitus: Absent
- [Other conditions listed similarly]
This approach aligns with hospital care delivery standards that require clear identification of diabetes status in the medical record for all patients 1