Diabetic SOAP

Nota completa

S: Here today for diabetes follow-up. Reports feeling well overall and no medication changes since the last visit. Denies symptomatic low glucose episodes.

Patient currently taking metformin 500 mg orally twice daily.

O/E
BP: 128/76 mmHg
Please see diabetes flow sheet below.
A1C: 7.6%, increased from 7.2%.
LDL: 92 mg/dL, decreased from 101 mg/dL.
HDL: 48 mg/dL, unchanged from 48 mg/dL.
Wt: 82 kg, increased from 80 kg.

A:
Diabetes under suboptimal control based on A1C trend.
LDL near target; continue monitoring.
Weight up from last appointment.
BP is at target.
Reviewed current medication routine and home glucose monitoring.

P:
Advised to continue a balanced diabetic diet and regular activity as tolerated.
Continue current medication regime; no adjustment made today.
Discussed recording home readings and bringing them to the next visit.
Will see back in three months for a diabetes visit.
Return sooner with persistent high or low readings or other concerns.

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S: Here today for diabetes visit. No changes in medication since last seen. Over all feels doing well. 

Patient currently taking (add diabetic medication)

O/E
BP:
Please see diabetes flow sheet below 
A1C: [current A1C] increased/decreased from [previous A1C]
LDL: [current LDL] increased/decreased from [previous LDL]
HDL: [current HDL] increased/decreased from [ previous HDL]
Wt: [current wt in kilograms ] increased/decreased from [previous wt in kilograms ]

A:
Diabetes under good/sub optimal control
LDL at target/not at target
Weight up/down from last apt
BP is at/not at target
Discussed insulin regime in detail 


P:
Advised to continue with diabetic diet/exercise etc
I have advised to continue with current medication regime
I have added the following medications to current regime:
I will see back in 3/6 months for diabetic visit 
See sooner with any other concerns