Family Medicine Specialist Template

Clearwater T2DM Severity Assessment

A professional Family Medicine Specialist template for healthcare professionals.

About this template

Need a quick and easy way to assess your patients' diabetes severity? This Clearwater T2DM Severity Assessment template is perfect for Family Medicine Specialists. It helps you systematically evaluate key indicators like A1C, blood pressure, ASCVD risk, and more. This template, when used with Heidi, will automatically populate the fields based on your patient's visit transcript, saving you time and ensuring comprehensive documentation. Easily calculate a total severity score and classify the patient's condition for better management and care. Simplify your diabetes assessments today!

Preview template

Type 2 Diabetes Severity Assessment Patient Information John Smith 12/03/1960 1234567 01 November 2024 Assessment Criteria and Scoring A1C 8.2 1 Blood Pressure 145/92 2 ASCVD Risk 12% 2 Waist Circumference 42 inches 3 BMI 32 2 Evidence of Fatty Liver Disease with AST/ALT lab scores AST: 30 ALT: 35 2 Diabetic Foot Exam Score 1 1 eGFR 55 2 Last Retinal Exam 06/06/2023 2 On Medications Metformin 1000mg twice daily, Lisinopril 20mg daily 3 Total Severity Score Calculation Add all individual scores together. Total calculated severity score: 18 Overall diabetes severity classification: Critical

Type 2 Diabetes Severity Assessment Patient Information [patient's full name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [patient's date of birth] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [patient's medical record number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [date of assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Assessment Criteria and Scoring A1C [patient's A1C value] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for A1C: 0 points for <7, 1 point for 7-9, 2 points for 9+, based on patient's A1C value] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Blood Pressure [patient's systolic and diastolic blood pressure readings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for blood pressure: 0 points for <130/80, 1 point for 130-140/80-90, 2 points for 140-160/90-100, 3 points for >160/100, based on patient's blood pressure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ASCVD Risk [patient's calculated ASCVD risk percentage] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for ASCVD risk: 1 point for <10%, 2 points for 15%, 3 points for >15%, based on patient's ASCVD risk] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Waist Circumference [patient's waist circumference measurement in inches] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for waist circumference: 0 points for <40” for men or <35” for women, 3 points for >40” for men or >35” for women, based on patient's waist circumference and gender] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) BMI [patient's calculated Body Mass Index (BMI)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for BMI: 1 point for 25-30, 2 points for 30-35, 3 points for >35, based on patient's BMI] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Evidence of Fatty Liver Disease with AST/ALT lab scores [patient's AST lab score] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [patient's ALT lab score] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for AST/ALT: 1 point for >25 for either, 2 points for >35 for either, 3 points for >45 for either, based on patient's AST/ALT scores] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Diabetic Foot Exam Score [number of missed spots during diabetic foot exam] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for diabetic foot exam: 0 points for no lack of sensitivity, 1 point for 1 missed spot, 2 points for 2 missed spots, 3 points for 3 missed spots, based on patient's diabetic foot exam findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) eGFR [patient's eGFR value] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for eGFR: 0 points for >90, 1 point for 60-90, 2 points for 45-90, 3 points for <45, based on patient's eGFR] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Last Retinal Exam [date of patient's last retinal exam] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for last retinal exam: 0 points for within 12 months, 1 point for >12 months, 2 points for >18 months, 3 points for >24 months, based on date of last retinal exam] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) On Medications [list of current diabetes medications and dosages, or indication of no medications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [severity score for medications: 0 points for no medications, 1 point for low dose metformin, 2 points for high dose metformin, 3 points for two or more medications, based on patient's medication regimen] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Total Severity Score Calculation [visual representation or instructions for calculating the total score from individual criteria] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [total calculated severity score] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [overall diabetes severity classification: 1-10 as moderate, 10-15 as severe, 15+ as critical] (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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