9. Documentation smart phrases
Disease-specific phrases that supplement the parent module’s phrases. Each is a scaffold to complete with the visit’s actual values and orders — never a substitute for individualized documentation.
.DX_DM_GLUCOSE Glucose log [range/pattern] over the interval vs the ordered individualized range [range]; out-of-range readings [number]; hypoglycemic events [number]; assessment [in control / out of range]. |
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.DX_DM_HYPO Hypoglycemia: lowest [value], symptoms [described], treated with [oral carb/glucagon per order], recheck [value]; unawareness [yes/no]; rescue available and not expired [yes/no]; [action]. |
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.DX_DM_DECOMP Decompensation screen: polyuria/polydipsia/dehydration/deep breathing/fruity odor/mental status [described]; ketones [checked/result]; assessment [none / DKA-HHS concern]; [action]. |
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.DX_DM_INSULIN Observed [insulin/pump/injectable] technique: dose per order, site rotation, storage [correct/corrected]; meter/CGM technique [correct]; [no] dosing errors. |
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.DX_DM_FOOT Feet [intact/lesion]; protective sensation [status per monofilament — see Touch/Sensation]; offloading/footwear [status]; [action] (see Wounds). |
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.DX_DM_SICKDAY Sick-day rules [verbalized correctly/re-taught]: continue insulin, monitor more often, check ketones, hydrate, when to call; A1c trend [value] vs individualized target. |
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.DX_DM_NOTIFY Provider notified at [time] of [finding]; orders received: [orders]; follow-through [completed/scheduled]; reassess [glucose pattern vs ordered range] next visit. |
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Cross-references. Endocrine/Metabolic (parent — general endocrine assessment) · Touch/Sensation (protective sensation) · Wounds (diabetic foot) · Eyes/Vision (retinopathy) · Urinary/Renal (nephropathy) · Nutrition · COPD overlay (steroid-induced hyperglycemia).