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Basic data

Here you can edit a patient's data if need be.

  • To save the new data click on .
  • If you want to compile a new sheet, click on .

Date of birth

Please enter in the format day.month.year. ( i.e. 24.12.2000 )

Initials

The first letters of a patient's name (can be for example used when searching for a patient so it may be quite useful) .

Gender

male oder female

Diabetes-type

Type 1 = IDDM
Typ 2 = NIDDM (even if it is treated with insulin)
others = pankreoprvic DM, nosologiscally unsolved cases, Gestationaldiabetes

Diabetes-Diagnosis

Year of diagnosis of Diabetes (values greater than 1920 or empty field)

Insulin since

Year that insulin therapy was begun(>1926 or empty)

OAD seit

Year that oral antidiabetics were begun (values> 1940 or an empty field if OAD were never taken).

Note: The orange fields are obligatory fields.


Physician and Date

To use the data, the blue fields are obligatory, they must be completely filled out.

Physician-ID

FQSD-ID of the examining physician
Important! This physician-ID-number is assigned by the center's administrator. If none has yet been assigned to you, please contact this person.

Date

Creation date of the sheet: The current date is entered as default.
!! Important !!
This date characterizes the sheed an is used in the analyses. If you enter "old" sheets be sure to enter the correct date.


Reasons for treating/ examining/ training the patient

Reason

was the patient admitted to the hospital or treated /examined / trained on an out-patient basis?
On the paper-form used during initial examination, other terms may be used (i.e. consult=out-patient and in-patient= admitted etc).
Exam-date
( ambulatory)
Here, the date of the consult/examination / training should be entered.
Length of stay ( from, to) (in-patient) If the patient was admitted to hospital, the date of admission and dismissal is entered.
The appropriate fields in the list below should be checked. Multiple entries are possible.

Routine

Routine check-up

Manifestation

Yes/ No

Patient education

Admission for structured schooling

Pregnancy

In combination with "other" type of diabetes means gestational diabetes

Sequaelae

i.e.: Renal insufficiency, heart attack

Emergency

Only emergency means Hypoglycaemia: Glucose or glucagon had to be injected or medical assistance was needed

Diab. Foot-syndrome

Admittance because of diabetic foot syndrome

Ketoacidosis

Hyperglycaemic, ketotic metabolic derailment requiring in-hospital treatment;
(in this case, check "emergency" also)

others

Can be defined by a center, must however be documented internally

Note: mandatory fields must be filled out.


Pregnancies

These fields should only be filled out if one or more completed pregnancies occured within the past 12 months.

The following distinctions can be made:

Normal

Number of normal pregnancies (range: 0-4 or empty)

Misscarriage

Number of spontaneous miscarriages or medically indicated abortions (range: < 10 or empty)

Deformity

Number of abnormalities (range: < 10 or empty)

Perinatal deaths

Number of perinatal deaths (range: < 10 or empty)

Note: These numbers refer only to the past 12 months .


Risk factors

(Average of the past 3 months)

If no risk factor was ascertained, these fields can be left empty.

Zigarettes/ day

Number or estimates, 1 pipe equals 3 cigatettes

Alcohol: g/ Week

Amount or estimate (Range :<1000 or empty)
50g / week = occasionally
100g / week = some
200g / week = moderate
300g / week = chronic alcoholism

Additional transformation table:
Drink
Amount
g Alcohol
Schnaps
1 glass (2 cl)
7 - 8
Cognac
2 cl
7 - 8
Whiskey
2 cl
7 - 8
Liqueur
4 small glasses
20
Wine
1/4 litre
20
Wine
1/2 litre
40
Beer
2 bottles à 0.5 litre
40


Self-check

Number of glucose self-checks performed by the patient per week (average of the past 3 months)

Blood -glucose

(Range <99 or empty)

Urin glucose

(Range <99 or empty)


Training / Self-help organisations

The entries refer to the last training before the actual time of examination.

The items "nutrition" through to "self-checks" (excluding "risk factors") must be affirmed to count as structured training .

No Information

If checked, the patient is not capable of giving credible information.

Schooling

Year of the last schooling prior to the examination (Range: >1920 or empty)

Tip: If you select Yes (or No) in the box , all elements are set to Yes (or No). Then you can simply change those fields which are still wrong to No (or Yes).


Mesurements

Depending on availability, the following values can be entered here:

  • either the last measured values, taken for example at a G.P.,
  • or the values taken at admission.

Weight

Body-weight of the patient in kilogram (range:0-300 or empty)

Size

Height of the patient in cm (range 40-250 or empty)
BMI

The Body Mass Index is calculated onhand weight and size and is thus not entered.
If the entered value is >40, a warning is shown. Combinations resulting in values > 90 are not allowed.

Bloodpressure

Patient`s blood-pressure in mmHg after 5 minutes rest in seated position with arm elevated/supported
(Ranges: Systolic: 70 - 300 or empty; Diastolic: 30 - 150 or empty)

Blood glucose

mg/dl (Range: 0 - 2000, or empty)

Hb

Current value in g/l (Range: 3 - 20 or empty)

HbA1c

Current value in % (Range: 4 - 40, or empty)

Creatinin

Value in mg/dl (Range: 0 - 20 or empty)

Microalbumin

Value in mg/l (Range: 0 - 9999 or empty)

Proteinurea

Value in g/l (Range: 0 - 30, or empty)

Cholesterol

Value in mg/dl or mmol/l (Range: 10 - 2000 or empty)

HDL-Cholesterol

Value in mg/dl (Range: 7 - 999, or empty)

Triglyceride

Value in mg/dl (Range: 8 - 9999 or empty)

LDL-Cholesterol

Value in mg/dl (Range: 10 -400, if no value is entered, the LDL is automatically calculated using the Friedemann-equation)

LDL-Cholesterol = Cholesterol - HDL-Cholesterol - Triglyceride/5

For immediate display of the calculated LDL-value, click on the button "calculate".

fasting

this value refers to the blood serum lipids

Note: The units correspond to those on the form. They can however be individually adapted to each center. These changes can be performed by the center's administrator under the menu Administration (submenu: settings).


St.Vincent - endpoints

If symptoms listed below occurred within the last 12 months, enter a Yes in the respective field.

Blindness

only if receiving state compensation for blindness

Heart attack

Yes/ No

Stroke

Hypertension-induced encephalomalacia or haemorrhage, not aneurysm

termin. kidney failure

Yes/ No

Amput. above ankle

only if the amputation was cuased by the diabetes

Amput. below ankle

only if the amputation was cuased by the diabetes

Tip: If you select Yes (or No) in the box , all elements are set to Yes (or No). Then you can simply change those fields which are still wrong to No (or Yes).


Symptoms in the last 12 months

If one of these symptoms occurred in the last 12 months, confirm these with Yes.

Orthostasis

Yes/ No

Angina pectoris

Yes/ No

Neuropathy

Symptoms caused by neuropathy

Claudicatio

Yes/ No

Erectile dysfunktion

Yes/ No

Note: Please ensure that for "Erectile dysfunktion" the "Male" gender was checked in the basic patient data.


Exams - Eyes

Only fill this out if a written result of an exam performed within the past 12 months is available.

Exam within the past 12 months

 

The values have to be entered for RIGHT and LEFT.

ever photocoagulated

 

cataract affecting eyesight

 

Retina visible

 

if the retina is visible:

 

clinically relevant macular edema

 

 

Retinopathy (3 levels)

  • mild/moderate
  • extensive, not proliferative
  • proliferative

advanced ocular damage

correlates to <20% vision

vision (in %)

% vision inkl. correction (range: 0 - 120 or empty)

Tip:

  1. If you select Yes (or No) in the box , all elements are set to Yes (or No). Then you can simply change those fields which are still wrong to No (or Yes).
  2. If you click on the symbol or the Form for Opthalomologist a new window opens showing you the form. You can then print it or save it on your hard disc. You must however have the Acrobat® Reader™ installed.

Exams - Feet

 

Should only be filled out if the feet were examined within the past 12 months.

normal vibratory sensation

Tuning fork examination

normal pain sensation

i.e. normal monofilament - test.

Puls detectable

Aa. dorsalis pedis (dorsal pedal artery) and Aa. tib. posterior (posterior tibial artery)

Healed Ulcer

Yes/No

Acute Ulcer

Yes/No

Bypass/Dilatation

Yes/No

Note: Abnormal vibratory or pain sensation is indicative of diabetic neuropathy.

Tip: If you select Yes (or No) in the box , all elements are set to Yes (or No). Then you can simply change those fields which are still wrong to No (or Yes).


Quality of life / Emergencies

(in the passt 12 months)

Hypoglycaemia

Incidents per year - glukose or glucagon must have been applied by somone other than the patient(Range: 0 - 99 or empty)

Hospitalization due to hypoglycaemia

Number per year (Range: 0 - 99 or empty)

Hyperglycaemia

Number/ Year
hyperglycaemic, ketotic metabolic derailments with hospitalization or hyperosmolaric emergencies (Range: 0 - 99 or empty)

WHO-Wellbeing Five

Indicator for wellbeing (Range: 0 - 25)

Sick days

Days per year - indepentant of origin (Range: 0 - 366 or empty)

Days of hospitalization

Days per year - indepentant of origin; including the current stay (Range: 0 - 366 or empty)


Diabetestherapy 

Please enter the year of initial therapy in the box (under initial ) of the respective medication (even if it is not currently prescribed). 

The "yes/no" fields are divided in two columns:

"To date"

(this consult) refers to the treatment give up to this point

"From now"

(this consult) refers to the treatment prescribed from this point on

 

Diet only

only "yes" if diet is the only treatment form

 

Biguanides

Year of first prescription (range>1949 or less)

Sulfonylureas

Year of first prescription (range>1949 or less)

Glukosidase inhibitors

Year of first prescription (range >1949 or less)

 

Other OAD

Year of first prescription (range >1949 or less)

 

Insulin -Units/day

Number (range: 0 - 999 or less)

Insulin-Injektions/day

Number, if under intensified insulintherapy (mixing basal- and normal insulin), count insulins seperately. (range: 0 - 9 or less)

Pen

Yes/ No

Pump

Yes/ No

other treatment

this item is undefined

Tip: If you select Yes (or No) in the box , all elements in the columnare set to Yes (or No). Then you can simply change those fields which are still wrong to No (or Yes).


Additional treatment

The "yes/no" fields are divided in two columns:

"To date"

(this consult) refers to the treatment give up to this point

"From now"

(this consult) refers to the treatment prescribed from this point on

The additional medication taken by the patient are entered here -subdivided into groups directly related to diabetes.

Hypertension

Yes/ No additional therapy

Heart failure

Yes/ No additional therapy

Cor. Heart disease

Yes/ No additional therapy

Dyslipidemia

if requiring more than insulin administration, Yes/ No additional therapy

Nephropathy

if requiring more than insulin administration, Yes/ No additional therapy

Neuropathy

if requiring more than insulin administration, Yes/ No additional therapy

Others

all other medications taken by the patient and not mentioned above, additional therapy

Tip: If you select Yes (or No) in the box , all elements in the columnare set to Yes (or No). Then you can simply change those fields which are still wrong to No (or Yes).


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