Common indicators for diabetes, IHD and COPD

• Smoking cessation – discussed once per year if smoker (document smoker or nonsmoker)
• Immunizations discussed and/or given – once per year
• Exercise/activity – discussed, including possible referrals, once per year

Common indicators for diabetes and IHD

• Blood pressure – 2 times per year
• Weight/nutrition counseling – once per year
• Lipids – once per year

Plus one, two or all three of the following as applicable:

Indicators for diabetes only

• HbA1C – ordered 2 times per year
• Renal function – ACR or eGFR ordered once per year
•  Foot exam with 10-g monofilament – referred or completed once per year
• Eye exam – discussed and/or referred once per year for routine dilated eye exam

Indicators for IHD only

• Anti-platelet therapy – considered/reviewed once per year
• Beta-blocker – considered/reviewed once per year
• ACEI/ARB – considered/reviewed once per year
• Discuss nitroglycerin – considered/reviewed once per year
• Consider further cardiac investigations – considered/reviewed once per year

Indicator for COPD only

• COPD Action Plan required – Develop and then review and complete once per year