I certify that diabetes self-management education services are needed. under a comprehensive plan for this patient’s diabetes care. …
MedStar Diabetes Institute at Good Samaritan Hospital
5601 Loch Raven Boulevard Baltimore, MD 21239-2995 Voice: 4105324884 Fax: 4105324550
Diabetes Self Management Education Physician Directive PAT I E N T I N F O R M AT I O N
Date:
Phone H: Address: Health Insurance:
Patients Name:
Phone W City, State, Zip:
SS DOB:
Pre-authorized visits : Type 1 Type 2 on insulin Type 2 oral agent Type 2 diet controlled
Diabetes Diagnosis:
GDM — EDC:__________________________
Pre-existing diabetes with pregnancy — EDC:__________________________
Other Diagnosis:
N E E D F O R D I A B E T E S E D U C AT I O N
Referral Certification and Reasons:
I certify that diabetes self-management education services are needed under a comprehensive plan for this patients diabetes care Check one or more of the following reasons for patient referral New onset diabetes in past 12 months A change in treatment regimen: No diabetes medications to diabetes medication From oral diabetes medications to insulin Inadequate glycemic control: A1C 85 on 2 or consecutive A1C determinations 3 or more months apart before the patient begins the education process AIC Date: ________________ AIC Date:
________________ Documented acute episodes of severe hypoglycemia or acute hyperglycemia occurring in the past year during which the patient needed ER visits or hospitalization High-risk based on at least one of the following documented complications: Lack of feeling in the foot or other foot complications such as foot ulcers, deformities, or amputations Pre-proliferative or proliferative retinopathy or prior laser treatment of eye Kidney complications related to diabetes, when manifested by albumin, without other causes or elevated creatinine
Barriers that Impede Patients Ability to Learn:
Visual/Hearing Impairment Learning Disability Impaired Mobility Impaired Mental Status Impaired Psychosocial Status Impaired Dexterity
Other: ____________________________________________________ __________________________________________________________
Management Plan of Care — The patient is to attend the following:
Comprehensive Diabetes Management Skills Training Medical Nutrition Therapy RD will provide 3 hours unless noted otherwise by physician Goal of Therapy ____________________________________________: Management of Diabetes during Pregnancy Insulin Pump Start Other:
____________________________________________________ __________________________________________________________
Lab Results or attach copies of labs
FBS A1C _______________mg/dl _______________ Date: _________________ Date: _________________ Date: _________________ Date: _________________ Date: _________________ Date: _________________ Date: _________________ Date: _________________
Microalbumin _______________ Cholesterol LDL HDL BP Triglycerides _______________mg/dl _______________mg/dl _______________mg/dl _______________Hgmm _______________mg/dl
Language Spoken:
English Other: ________________________________________
R E F E R R I N G P H YS I C I A N I N F O R M AT I O N
Physician Signature: Physician Name: Print Address: City, State, Zip: Phone: Fax:
Fo r S t a f f Us e O n l y
Adm: Appointment Date and Time:
062802
Dr:
Reminder:
