4. Key visit elements — in addition to the Endocrine / Metabolic assessment

In addition to the full Endocrine / Metabolic assessment (the general endocrine exam and metabolic status documented there), the diabetes overlay adds each visit:

• The glucose-log pattern stated against the ordered individualized range — for example “self-monitored 95–160 over the week, within the ordered 80–180” — rather than “glucose at baseline,” with the number and timing of any out-of-range or hypoglycemic readings.
• Hypoglycemic events over the interval, their severity, and whether hypoglycemia unawareness is present, and the availability and expiration of the rescue (oral carbohydrate and glucagon per order).
• Insulin, pump, or injectable-agent technique and meter or continuous-glucose-monitor technique on direct observation.
• Decompensation screen — polyuria, polydipsia, dehydration, deep rapid breathing or a fruity odor, and mental status — and ketones where the threshold is met.
• The diabetic-foot screen — skin integrity and protective-sensation status (detail in Touch/Sensation; wounds in Wounds).
• Medication adherence and any recent regimen change, and steroid use that raises glucose (cross-reference COPD overlay where applicable).
• The A1c and its trend against the individualized target where available, and the interval since the last dilated eye exam and renal-function check (cross-reference Eyes/Vision and Urinary/Renal).
• Nutrition and carbohydrate consistency as they affect the pattern (cross-reference Nutrition).