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Audit Form NDR/Audit/version_1.

0/2010

No.

DIABETES CLINICAL AUDIT

Health Facility: KLINIK KESIHATAN SALAK Clinic Type: FMS / MO / AMO

Name of Patient: IC No.:

Date of Birth: Sex: Male / Female

Date Diabetes Diagnosed: Ethnicity:

*estimate/presumed

Criteria Latest results Date of latest results


Not done
(past 1 year)

Height cm

Weight kg / /
Waist circumference cm / /
2
Body Mass Index (BMI) kg/m / /
Blood pressure mmHg / /
Random Blood Sugar (RBS) mmol/L / /
Fasting Blood Sugar (FBS) mmol/L / /
2-hour Post Prandial (2HPP) mmol/L / /
HbA1c % / /
Total: mmol/L / /
TG: mmol/L / /
Serum
cholesterol HDL: mmol/L / /
LDL: mmol/L / /
Creatinine mol/I / /
Microalbuminuria Positive / negative / /
Proteinuria Positive / negative / /
Fundus examination Normal / abnormal / /
Foot examination Normal / abnormal / /
ECG test Normal / abnormal / /
Screening for Erectile Dysfuntion Normal / abnormal / /

Patient examined by MO at least once within 1 year of audit Yes No

* Estimate/presumed: If exact date not known and only the year is known, please fill date as 30/06/yyyy and tick the adjacent box
Note: For Diabetes-related complications, date of diagnosis can be at any point in time after
diagnosis of diabetes.

Complication Present Absent Not If PRESENT, date of *Estimate/


known diagnosis presumed

Retinopathy / /
Ischaemic heart disease / /
Cerebrovascular disease / /
Nephropathy / /
Diabetic foot ulcer / /
Amputation / /

Concomitant Co-morbidity Yes No Not If YES, date of *Estimate/


known diagnosis presumed

Hypertension / /
Dyslipidaemia / /

Diabetes medications Yes Anti-hypertensives Yes

Biguanides (e.g. metformin) ACE-Inhibitor

Sulphonylureas (e.g. glibenclamide) ARB

-glucosidase inhibitors (acarbose) Beta-blockers

Meglitinides (e.g. repaglinide) Calcium channel blockers

Glitazones (e.g. rosiglitazones) Diuretics

Others:_________________________ Alpha-blockers

Insulin Centrally acting

Anti-platelets Yes Others:_________________________

Acetyl salicylate acid (aspirin) Lipid-lowering agents Yes

Ticlopidine Statin

Others:_________________________ Fibrate

Others:_________________________
Signature :
Name : Date of audit :

* Estimate/presumed: If exact date not known and only the year is known, please fill date as 30/06/yyyy and tick the adjacent box

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