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Community Nurse Template

Diabetes Clinic - Community Nurse Note

A professional Community Nurse template for healthcare professionals.
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About this template

This Community Nurse Note template is designed for nurses to efficiently document diabetes clinic reviews. It's ideal for community nurses managing patients with diabetes, allowing for comprehensive recording of diagnoses, medications, history, foot assessments, eye and kidney care, and cardiovascular disease (CVD) management. The template includes sections for HbA1c results, hypoglycaemia management, and sick day care advice. This template helps streamline the documentation process, ensuring all critical aspects of diabetes care are addressed. With Heidi, this template can be quickly populated from a visit transcript, saving time and improving accuracy.

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**Diabetes Clinic Review** **Diabetes Diagnosis** - Type 2 Diabetes, diagnosed on 12 June 2018, based on fasting plasma glucose of 14.2 mmol/L. **Medications** - Metformin 1000mg twice daily, taken regularly with no reported side effects. - Gliclazide 80mg once daily, patient reports occasional mild hypoglycaemic episodes. **History** - Previous hospitalisation for diabetic ketoacidosis in August 2020. No other significant comorbidities. **Consent for HbA1c** - Consent obtained for HbA1c test. Patient understands the test and its purpose. **Foot Assessment and Care (for Type 2 Diabetes)** - Pedal pulses palpable bilaterally. Sensation intact to light touch. No skin breakdown or ulceration noted. Patient educated on daily foot inspection and proper footwear. **Questions about Complications of Diabetes** - Patient enquired about the risk of diabetic neuropathy and retinopathy. **Eye Care** - Last eye examination was 6 months ago, with no evidence of diabetic retinopathy. Next examination scheduled for 12 months. **Kidney Care** - eGFR 65 ml/min/1.73m2. Urine albumin-creatinine ratio (UACR) within normal limits. Discussed importance of blood pressure control for kidney health. **CVD Care** - Blood pressure 135/85 mmHg. LDL cholesterol 3.5 mmol/L. Patient advised on the importance of regular exercise and a healthy diet. No pharmacological interventions required at this time. **Managing Hypoglycaemia** - Patient reports experiencing mild hypoglycaemic episodes approximately once a month. Discussed strategies for managing hypoglycaemia, including adjusting medication dosages and carrying glucose tablets. **Sick Day Care** - Provided advice on sick day management, including monitoring blood glucose levels more frequently and adjusting insulin dosage as needed. Advised to seek medical attention if experiencing persistent vomiting or high blood glucose levels. **HbA1c Result** - HbA1c result: 7.8% (62 mmol/mol). Discussed the result and the need for improved glycaemic control. **Recommendations** - Referral to a dietician for further dietary advice. Review medications at next appointment. Follow up HbA1c in 3 months. Date: 1 November 2024
**Diabetes Clinic Review** **Diabetes Diagnosis** - [document the current diabetes diagnosis, including the type of diabetes, date of diagnosis, and diagnostic criteria if available] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Medications** - [list all current medications related to diabetes, including dosage, frequency, and route, and any other relevant medications or supplements, clearly indicating adherence and any side effects] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **History** - [capture relevant medical history pertaining to diabetes management, including previous treatments, hospitalizations, significant complications, and other comorbidities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Consent for HbA1c** - [document whether consent was obtained for an HbA1c test, including the patient's understanding of the test and agreement] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Foot Assessment and Care (for Type 2 Diabetes)** - [detail the findings of the foot assessment, including sensation, circulation, skin integrity, and any observed deformities or concerns; also document specific foot care advice given] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Questions about Complications of Diabetes** **Eye Care** - [document discussions regarding eye care, including the date of the last eye examination, findings, and any recommendations for future examinations or interventions related to diabetic retinopathy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Kidney Care** - [record information related to kidney care, including results of kidney function tests, presence of proteinuria, and discussions about strategies to protect kidney health in the context of diabetes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **CVD Care** - [capture details regarding cardiovascular disease (CVD) risk assessment and management, including blood pressure, lipid profile, and any recommendations for lifestyle modifications or pharmacological interventions to reduce CVD risk] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Managing Hypoglycaemia** - [describe the patient's understanding and experience with hypoglycaemia, including frequency, symptoms, causes, and methods for management and prevention discussed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Sick Day Care** - [document education and advice provided regarding sick day management for diabetes, including medication adjustments, monitoring, and when to seek medical attention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **HbA1c Result** - [discuss the HbA1c result, including the value, clinical interpretation, and any related follow-up actions or discussions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Recommendations** - [list any specific product recommendations, referrals to pharmacy services, or lifestyle advice given to the patient for diabetes management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
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Specialty

Community Nurse

Used

19 times

Type

Note

Last edited

18/10/2025

Created by

Morgan Werrett

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