Community Review patient medication Develop/update medication New/updated medication Pharmacist profile management plan: management plan to patient Assess medication patient current medication list management (education, assessment result; Summary care plan and conformance, etc.) needs progress note shared with recommendation on meds and strategies primary care provider and management; referral to other to other care providers, Discuss and finalize provider(s) if necessary e.g., diabetic educator, medication management dispense record on dispensed meds dietitian, etc. plan Update clinical notes Generate progress notes Clinical Review referral/patient Develop/update psychological New/updated Psychologist progress management plan: psychological management plan to Assess emotional status, Emotion assessment; patient coping mechanisms and Psychotherapy session plan strategies Summary care plan and Update clinical progress note shared with Discuss and finalize Generate progress notes primary care provider and psychological management care providers, e.g., plan diabetic educator, dietitian, etc. Optometrist Review referral/patient Develop/update eye care plan: New/updated eye care progress plan to patient Regular eye checks for Assess eye care needs and detection of Diabetic retinopathy Summary care plan and strategies (1yearly to 2 yearly depending on progress note shared with national protocol and how advanced primary care provider and Discuss and finalize eye is DM) other care providers, e.g., care plan diabetic educator, Stop smoking (prevent smoking dietitian, etc. related damage to eye Wear sun glasses when in sun (prevent UV accelerating eye damage) dispense prescription sun – glasses if necessary; Referral to Dietitian/Nutritionist for counseling on diet rich in fruits and leafy veg and Omega 3 fats along with effective weight control Update clinical Generate progress notes Podiatrist Review referral/patient Develop/update foot care plan New/updated foot care progress plan to patient Foot assessment Assess foot care needs and Summary care plan and Foot care plan strategies progress note shared with Update clinical notes primary care provider and Discuss and finalize foot Generate progress notes other care providers, e.g., care plan diabetic educator, dietitian, pharmacist, etc.
Community Pharmacist Review patient medication profile Assess medication management (education, conformance, etc.) needs and strategies Discuss and finalize medication management plan Develop/update medication management plan: patient current medication list assessment result; recommendation on meds management; referral to other provider(s) if necessary dispense record on dispensed meds Update clinical notes Generate progress notes New/updated medication management plan to patient Summary care plan and progress note shared with primary care provider and to other care providers, e.g., diabetic educator, dietitian, etc. Clinical Psychologist Review referral/patient progress Assess emotional status, coping mechanisms and strategies Discuss and finalize psychological management plan Develop/update psychological management plan: Emotion assessment; Psychotherapy session plan Update clinical Generate progress notes New/updated psychological management plan to patient Summary care plan and progress note shared with primary care provider and care providers, e.g., diabetic educator, dietitian, etc. Optometrist Review referral/patient progress Assess eye care needs and strategies Discuss and finalize eye care plan Develop/update eye care plan: Regular eye checks for detection of Diabetic retinopathy (1yearly to 2 yearly depending on national protocol and how advanced is DM) Stop smoking (prevent smoking related damage to eye Wear sun glasses when in sun (prevent UV accelerating eye damage) – dispense prescription sun glasses if necessary; Referral to Dietitian/Nutritionist for counseling on diet rich in fruits and leafy veg and Omega 3 fats along with effective weight control Update clinical Generate progress notes New/updated eye care plan to patient Summary care plan and progress note shared with primary care provider and other care providers, e.g., diabetic educator, dietitian, etc. Podiatrist Review referral/patient progress Assess foot care needs and strategies Discuss and finalize foot care plan Develop/update foot care plan Foot assessment Foot care plan Update clinical notes Generate progress notes New/updated foot care plan to patient Summary care plan and progress note shared with primary care provider and other care providers, e.g., diabetic educator, dietitian, pharmacist, etc.