Diabetes Assessment & Management Plan

(Residential Aged Care Homes)

Date: ______

Doctor: ______

Diabetes status: q Type I q Type 2 Using Insulin? q Yes q No

Diabetes medications: ______

Dietary plan: ______

Frequency of blood glucose monitoring: Days of week:______Times of day ______

Risk of HYPO in this resident is: q high q medium q low q unknown

Annual Cycle of Care (indicate when test is due, insert result when test completed)

Minimum recommended intervals / Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
6 monthly / Weight (kg)
Or BMI
Blood Pressure
Foot check
(Podiatrist)
12 monthly / HbA1C
Goal _____
Urine Microalbumin
Lipids
U&E Creat
2 yearly / Eye check
(Optometrist/
Opthalmologist)

Blood Glucose Levels (BGL) and actions by flow diagram

GP signature ______Date: ______

The following may be symptoms of hypoglycaemia (low blood glucose)

Note: these symptoms may be absent in the elderly


Developed by North East Valley Division of General Practice, Aged Care GP Panels Initiative, May 2007 Updated Aug 2012

·  sweating

·  dizziness

·  trembling

·  pallor

·  hunger

·  anxiety

·  tingling (especially hands, feet or tongue)

·  blurred vision or vision changes

·  difficulty concentrating

·  confusion

·  tired/drowsy

·  slurred speech or difficulty speaking

·  unconscious


Developed by North East Valley Division of General Practice, Aged Care GP Panels Initiative, May 2007 Updated Aug 2012

The following may be symptoms of hyperglycaemia (high blood glucose)


Developed by North East Valley Division of General Practice, Aged Care GP Panels Initiative, May 2007 Updated Aug 2012

·  excessive urination

·  excessive thirst

·  dry mouth

·  tiredness/fatigue

·  blurred vision

·  nausea/vomiting


Developed by North East Valley Division of General Practice, Aged Care GP Panels Initiative, May 2007 Updated Aug 2012

GP signature ______Date: ______

References consulted include:

1) RACGP Diabetes management in general practice – Guidelines for type 2 diabetes 2011/2012

2) Therapeutic Guidelines – Endocrinology Version 4 2009


Developed by North East Valley Division of General Practice, Aged Care GP Panels Initiative, May 2007 Updated Aug 2012