Copy of Snippet "diabetes"

SOAP note for diabetes -mb

CC: diabetes, {formmenu: default=EV; RV}/{formmenu: default=ICF; SN}
DOB:{formdate: MM/DD/YYYY}

Review of Systems: as per HPI, otherwise a 12 point ROS was obtained and is negative

Fasting glucose: {formtext: name=#}
Postprandial and bedtime glucose: {formtext: name=#1}
Vital Signs: T-{formtext: name=Temp}, P-{formtext: name=pulse}, R-{formtext: name=resp}, B/P-{formtext: name=b/p}, SpO2-{formtext: name=spo2},{formparagraph: name=wt; rows=1}lbs

General: Alert, awake, pleasant and cooperative.
HEENT: Head normocephalic and atraumatic
Conjunctiva clear, PERRL. EOMI.
External ear canals clear. Nares normal, no drainage or sinus tenderness.
Lips, mucosa, and tongue normal 
Neck: Supple, symmetrical, without adenopathy
Lungs: BBSCTA, NAD. No wheezes, rhonchi or crackles
CV: RRR, S1, S2. No murmur noted
Abdomen: Soft, NT, ND, + BS x 4Q
Genitourinary: deferred
Extremities: no edema, + pulses, no cyanosis/clubbing
Musculoskeletal: no tenderness to palpitation, no deformities or contractions noted
Neurological: CN II-XII grossly intact
Skin: Color normal, skin warm and dry
Psychiatric: normal mood and affect

{time: MM/DD/YYYY}
HgA1c: {formtext: name=amount} 
Last HgA1c was:{formtext: name=amount1} on {formdate: MM/DD/YYYY; name=date2}


Continue medications, labs and treatments
Decrease fall and aspiration risk
Appropriate for {formmenu: default=ICF; SN, PT, OT}
Complex patient with multiple comorbidities
For those {formmenu: without major comorbidities; default=with multisystem disease}, an A1C goal of {formmenu: 7-7.5%; default=7.6-8.5%} is recommended to minimize the risk of hypoglycemia and metabolic decompensation.
Will continue to check A1C every 3-6 months.
Educated on the signs and symptoms of hypoglycemia: excess sweating, hunger, fainting, fatigue, slurred speech, nausea, headache, palpitation.
Educated on eating appropriate food and making better choices. 
Resident in agreement with the above plan of care.
Resident given the opportunity to ask questions, all questions answered. Encouraged to notify nursing staff for additional questions or concerns.