Diabetes Management Note (Outpatient)

Date/Time: [Encounter date and time]

Provider: [Name, credentials]

Visit Type: [new / follow-up]; [diabetes-focused / comprehensive]

Diabetes Summary

Diabetes type & duration: [Type 1 / Type 2 / Other] — [Years since diagnosis]

Current therapy category: [lifestyle only / non-insulin / basal insulin / basal-bolus / pump / AID]

Most recent A1C: [Value and date / No recent A1C on file]

CGM use: [Y / N]; [Device if applicable / CGM data not available]

Hypoglycemia risk flag: [Severe hypoglycemia history / Impaired awareness / High-risk regimen / None]

Key complications: [CKD stage / Retinopathy / Neuropathy / ASCVD / HF / None]

Individualized glycemic targets: [A1C goal]; [CGM goals if applicable]

Subjective

[Purpose of visit, patient-stated goals, and interval changes since last visit including ED visits, hospitalizations, steroid use, or major regimen changes] (Include a brief direct quote when it clarifies patient priorities or barriers.)

Current diabetes regimen: (Provide enough detail to safely titrate. If dosing is uncertain, state "Dosing unclear—verify with patient/pharmacy.")

• Non-insulin agents: [Medication name(s), dose(s), schedule, tolerance]
• Insulin: [Basal: name, units, timing]; [Prandial: fixed doses or ICR/CF/target]
• Pump/AID: [Device]; [Key settings: basal profile, ICR, CF, target, active insulin time]; [Auto-mode % time]

Hypoglycemia and safety screen: (Mandatory at every visit)

• Episodes <70 mg/dL: [Frequency, timing, triggers]
• Severe hypoglycemia since last visit: [Y / N]
• Hypoglycemia awareness: [Intact / Impaired / Unknown]
• Safety concerns: [Driving / Workplace / None reported]

Adherence and barriers: [Missed dose patterns with context—cost, side effects, forgetfulness, device issues, food insecurity, work schedule] (Describe specific behaviors; avoid labeling without context.)

Relevant lifestyle factors: [Meal timing, carbohydrate variability, physical activity, weight trajectory] (Include only if pertinent to today's management.)

Objective

Vitals: [BP, HR, weight, BMI as relevant]

Exam: (Document pertinent findings only; do not auto-populate normal findings not assessed.)

• [Injection/infusion sites: normal / lipohypertrophy / irritation]
• [Foot inspection findings]
• [Comprehensive annual foot exam: performed today / deferred]

Labs: (Include available results; note overdue labs as gaps.)

• A1C: [Value and date / No recent A1C on file]
• eGFR: [Value and date]
• UACR: [Value and date]
• Lipids: [LDL, HDL, TG with date]
• Overdue: [List tests due or not on file]

Glucose Data: (Document only what was actually reviewed; do not infer CGM metrics.)

• CGM:
  • Device and dates: [Device]; [Date range]
  • Wear: [% time active] (If <70%, note data limitation.)
  • Mean glucose: [mg/dL]; GMI: [%]; CV: [%]
  • TIR 70–180: [%]; TBR <70: [%]; TBR <54: [%]; TAR >180: [%]; TAR >250: [%]
  • Notable patterns: [Hypoglycemia timing, postprandial excursions, overnight trends, variability]
• SMBG (if CGM not available): [Frequency, data source, typical ranges, notable patterns]
• If no data available: [CGM data not available / Insufficient SMBG records]

Screening Status: (Include dates; status: done / due / ordered / deferred)

• Eye exam: [Date and status]
• Kidney screening (UACR/eGFR): [Date and status]
• Neuropathy assessment: [Date and status]
• Annual comprehensive foot exam: [Date and status]
• Vaccinations: [Relevant vaccines and status]

Assessment

Diabetes Mellitus: [Type], [current control status]

[Glycemic control assessment citing A1C and/or CGM metrics with dates; hypoglycemia risk characterization; key drivers of current patterns; complications or comorbidities impacting targets] (Do not copy forward "controlled" or "uncontrolled" without citing objective data.)

Additional Problems

• [Problem name]: [Brief synthesis with objective data] (Include only problems addressed today.)

Plan

Diabetes Mellitus

• Targets: [A1C goal]; [CGM goals: TIR, TBR, TAR thresholds]
• Changes made today: [Specific medication/device changes with exact dosing and rationale tied to data]
• Ongoing therapy: [Current medications/devices continuing unchanged]
• Titration instructions: [How to adjust, thresholds, max/min dosing, stopping rules, when to contact clinic]
• Safety: [Hypoglycemia prevention, sick-day/ketone guidance, driving safety]
• Education provided: [Topics covered and patient comprehension]

Additional Problems

• [Problem name]: [Plan with specific interventions, monitoring parameters, and safety rules]

Orders

• Labs: [Tests ordered with timing]
• Medications/supplies: [Prescriptions, insulin quantities, CGM/pump supplies]
• Referrals: [Ophthalmology / DSMES / Podiatry / Nephrology / Nutrition / Other]

Follow-up

• Return in: [Timeframe]
• Before next visit: [Upload CGM data / Bring meter and logs / Complete labs by date]
• Contact clinic urgently for: [Severe hypoglycemia, ketones with symptoms, persistent severe hyperglycemia, vomiting/dehydration, pump failure without backup]