ESBD_515780_1778790188516_Attachment 04-VR2888 Diabetes Self-Management Education Assessment.pdf
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- Solicitation number
- 3202600156
- Issued by
- Texas
About this file
This is a Diabetes Self-Management Education Assessment form used by the Texas Workforce Commission Vocational Rehabilitation Services (VR) to evaluate customers with diabetes and develop individualized education and training plans. The form is designed to comprehensively assess a customer's understanding and management of their diabetes across multiple domains, including diabetes history, healthy eating, physical activity, blood glucose monitoring, medication management, healthy coping strategies, problem-solving skills, and risk reduction. The assessment captures customer demographics, support systems, occupational history and goals, and current diabetes-related complications or risk factors. Based on the assessment findings, the diabetes educator develops a customized education plan that specifies the number of minutes and key topics needed for training in each domain, with recommendations for culturally appropriate instruction methods that address the customer's learning style and barriers.
The form serves as a billing and documentation instrument for VR service providers, requiring certification by a qualified diabetes educator and, for Traditional-Bilateral Contractors, approval by a director holding UNTWISE credentials. Equipment recommendations are provided based on assessment findings, including blood glucose monitors with audio or non-audio features, lancets, insulin delivery devices, blood pressure monitors, and adaptive kitchen tools for customers with disabilities. A technical review by VR staff verifies that services were provided within the authorized service dates, that sessions met the required two-hour minimum duration, that invoicing was appropriate, and that the form was submitted within 35 days of completion. The VR counselor reviews the assessment to confirm that services met the customer's individual needs and align with VR-SFP specifications before approving payment of the provider's invoice.
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VR2888 (02/23) Diabetes Self-Management Education Assessment Page 1 of 11
Texas Workforce Commission Vocational Rehabilitation Services
Diabetes Self-Management Education Assessment
Instructions
• Complete all appropriate fields. Boxes not marked indicate it does not apply to this customer.
• Develop education and support plan in the “overall recommendations” section.
• Set behavior change goal for next visit.
• As appropriate, you may use the following abbreviations: NA for “not applicable”, ND for “not disclosed by customer”, or NE for “not evaluated”.
Customer Information Customer name: TWS-VRS Case ID:
Referral date: Counselor name: Service authorization number:
Customer Demographics Age: Sex: (check box):
M F
Marital status:
Married Divorced Single Widowed
Number in household (including customer):
Physician name, specialty, and contact information handling Diabetes Management:
Primary and secondary insurance (if applicable):
Can customer meet diabetes-related expenses (e.g. nutritional needs, medications, test strips)?
Yes No
If no, enter explanation and/or comments:
Community resources used by customer:
Support System Primary support person and relationship: Telephone number:
Does the customer have disability assistance available when needed? Yes No
Does the customer currently receive home health services? Yes No
Does the customer belong to and/or attend any diabetes or disability support groups?
Yes No
EXAMPLE
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Diabetes History
Diabetes: Type 1 Type 2 Gestational Duration: years Has the customer participated in formal diabetes education in the past? Yes No
If yes, when?
Does the customer understand the pathophysiology of diabetes? Yes No
Does the customer have any of the following lifestyle or risk factors?
(Please report any risk factors that may affect the customer’s ability to participate in rehabilitation training to the VRC or OIB Worker directly.)
Family history of diabetes Over age 45 Unhealthy alcohol consumption Smoking High blood pressure Obesity
Customer’s height: Customer’s weight: lb.
Does the customer currently have or has been told he or she is at high risk for any of these complications?
Foot problems Neuropathy Renal problems Cardiovascular problems
Other complications (describe):
Has the customer been to the emergency room or hospitalized in the last 6 months?
Yes No
If yes, explain:
Diabetes Self-Management Education Assessment Vocational Rehabilitation (for VR customers only) What is the customer’s previous occupation?
What is the customer’s current occupational goal?
Has the customer ever missed work or school because of diabetes? Yes No Does the customer need frequent breaks for self-care at work?
Yes, for frequent snacks and meals Yes, for monitoring Yes, for medication No
Is the customer able to monitor his blood sugar independently?
Yes, with audio meter Yes, with non-audio meter No, but wants training to be independent No, is unwilling or unable to monitor independently
Does the customer understand diabetes-related impact on employment?
Yes No, but customer is ready to learn No, and customer is unwilling or unable to learn
Does the customer have a plan for discussing his or her diabetes with people at work?
Yes, customer is comfortable sharing information about diabetes and managing it in front of co-workers Yes, customer understands the importance of discussing diabetes with co-workers, but wants to settle in before beginning the conversation
No, customer needs instruction on what to discuss with co-workers and how No, customer feels that diabetes is a personal matter and none of the co-worker’s business
VR2888 (02/23) Diabetes Self-Management Education Assessment Page 3 of 11
Comments and recommendations regarding Vocational Rehabilitation:
Healthy Eating (VR and OIB) Does the customer understand the effect of these foods on blood sugar?
Carbohydrates Proteins Fats None of these. Customer needs full education on the macronutrients
Can the customer verbalize appropriate portion sizes?
Carbohydrates Proteins Fats No. Customer needs training on portion sizing Is the customer able to verbalize healthy meal options?
Breakfast Lunch and Dinner Snacks No. Customer needs training on meal options.
Does the customer understand the importance of timing of meals?
No, needs full education on timing of foods and medications Customer’s meals are well spaced but needs information about timing and medication Yes, customer follows meal and medication plan at least 80% of the time
What concerns does the customer have regarding healthy eating?
Food preferences Religious or cultural considerations Cost and availability of healthy foods No concerns
Does the customer need education on these eating habits?
Restaurants, Alcohol, and fast food Ability to prepare healthy foods Dietary restrictions related to health status (low fat, low salt, renal, etc.) None of these concerns
Comments or recommendations regarding healthy eating:
Being Active (VR and OIB) What physical problems limit the customer’s ability to exercise?
Hypoglycemia or Hyperglycemia Physical disability Motivation Customer should be able to participate in exercise.
Does the customer have resources for exercise?
Treadmill, stationary bike, or other cardiovascular equipment Weights Workout videos or games None
What activities has the customer enjoyed in the past?
What activities would the customer like to do?
What is the customer’s current exercise level?
None Seldom. Customer exercises less than one hour per week Occasionally. Customer exercises two to four hours per week Regular. Customer exercises five or more hours per week
Comments or recommendations regarding being active?
Monitoring (VR and OIB) Does the customer have a blood glucose meter and testing supplies?
Yes, an audio meter and supplies Yes, a meter and supplies without audio features No, customer needs an audio meter and supplies No, customer wants a meter and supplies without audio features
VR2888 (02/23) Diabetes Self-Management Education Assessment Page 4 of 11
Current meter:
Frequency of testing:
Current blood glucose reading:
Premeal Post meal
Date: Time: Result:
Does the customer know his or her most recent A1c?
Yes No Result:
Does the customer:
Understand how to use the meter and get a drop of blood to the test strip
Show willingness to monitor his or her blood sugar?
Need education or motivation to monitor
Monitoring is not recommended for this customer
Does the customer know how to respond to the results?
Yes, regarding adjustments in medications Yes, regarding adjustments in food Yes, regarding treatment of hypoglycemia and hyperglycemia and seeking medical help No, Customer does not know how to respond to the results
Is the customer able to verbalize appropriate results?
Customer can verbalize individual blood sugar goals Customer can verbalize Hemoglobin A1c goals Customer can verbalize blood pressure goals Customer needs training on monitoring goals
Does the customer monitor other health metrics?
Weight Ketones Blood pressure none of these
How does the customer currently check his or her blood pressure?
Doctor’s office Pharmacy or grocery Home Does not check
What keeps the customer from monitoring?
Customer does not believe the results are useful Customer is unable to perform tasks independently Cost and availability of supplies Customer currently monitors appropriately.
Is the customer able to:
Retrieve values from the meter’s memory and/or keep a record of results of blood sugars and other data Dispose of lancets and syringes appropriately Adjust his or her diet, medication, and activity based on results Customer uses results in day to day diabetes management
Comments or recommendations regarding Monitoring?
Taking Medication (VR and OIB) List of current medications
Medication Dosage Frequency Condition
1.
2.
3.
VR2888 (02/23) Diabetes Self-Management Education Assessment Page 5 of 11
4.
5.
6.
7.
8.
9.
10.
11.
12.
List any allergies (food or drug):
How is insulin or injectable medication drawn and administered?
Independently without assistive devices Independently using assistive device (describe in comments) Support person assists in insulin administration Customer does not take insulin or other injectable
Does the customer verbalize information about insulin?
Customer verbalizes how to draw and administer, appropriate storage and travel Customer verbalizes appropriate injection sites and proper site rotation Customer verbalizes onset, peak, and duration Customer needs full training on insulin
Is the customer able to manage other medications?
Customer has an organized method for storing and managing medications Customer needs instruction on storing and managing medication Customer uses vitamins and other alternative medicine (describe in comments) Customer is able to manage other medications
The customer:
Knows the purpose of his or her medications and how it works Takes medications as recommended Knows when to notify the doctor and knows what to ask when prescribed a new medication Customer needs training on medication(s).
Comments and recommendation regarding taking medication:
VR2888 (02/23) Diabetes Self-Management Education Assessment Page 6 of 11
Healthy Coping (VR and OIB) How does the customer feel about having diabetes?
Customer is in charge of the diabetes Customer doesn’t like it, but does the self-care tasks anyway Customer tries to manage it, but feels there is not much he or she can do Diabetes is in charge of customer
Does the customer have a support system?
Family and friends are physically and emotionally available to help customer Family and friends help customer in ways that the customer is resistant to receive There are family and friends available, but they have given up on helping customer Customer has no support system
Does the customer have any issues regarding depression and diabetes?
Customer feels hopeful about the future and diabetes is manageable Customer has minor symptoms such as occasional blues, fearfulness, and sleeplessness Customer is okay right now but has been depressed in the past and is concerned about depression returning Customer is currently depressed and finds it difficult to deal with diabetes and other health issues
What does the customer do to manage stress?
Customer is not familiar with stress management techniques Customer uses prayer, deep breathing exercises, affirmations, etc.
Customer has a strong support system Customer uses exercise and/or other active techniques
What help would the customer like regarding healthy coping?
Books, audio, website, and community resource recommendations Help with “diabetes police” and other caregiver concerns Help dealing with depression and diabetes issues Customer declines assistance with healthy coping
Comments and recommendations regarding healthy coping:
Problem Solving (VR and OIB)
What does the customer know about hypoglycemia?
Customer can verbalize the signs and symptoms and his or her personal response Customer can verbalize appropriate treatment Customer can verbalize a plan should hypoglycemia happen at work Customer needs training on hypoglycemia
What does the customer know about hyperglycemia?
Customer can verbalize the signs and symptoms and his or her personal response Customer can verbalize appropriate treatment Customer can verbalize a plan should hyperglycemia happen at work Customer needs training on hyperglycemia
VR2888 (02/23) Diabetes Self-Management Education Assessment Page 7 of 11
What does the customer know about sick days?
Customer understands the importance of monitoring, taking medication, eating, and staying hydrated Customer has a sick day kit put together with cold medicines and other things needed to manage when he or she is sick
Customer can verbalize when to call the doctor Customer needs education on managing sick days
The customer is able to:
Perform a foot examination and verbalize appropriate skin and wound care Verbalize the importance of wearing medical identification Choose appropriate clothing, shoes and socks that are not binding Customer needs training on foot and skin care.
Comments and recommendations regarding problem solving:
Reducing Risk (VR and OIB)
Does the customer participate in risky behaviors?
Customer smokes Customer has problems with drugs or excessive alcohol usage Customer has participated in risky behaviors in the past and needs education about effect on health Customer does not smoke, drink excessively or have problems with drugs
Does the customer understand the consequences of diabetes mismanagement?
Cardiovascular risk including stroke Neuropathy and amputation risks Kidney disease risk Dental disease risk Customer needs training on risks of diabetes mismanagement.
Does the customer participate in regularly scheduled healthcare?
Regular doctor’s visits including a discussion of laboratory values for diabetes risk factors and immunizations
Annual eye exams (minimum) Annual dental exams Foot exams by a professional Customer does not participate in scheduled healthcare (describe in comments)
Comments and recommendations regarding reducing risk:
Overall Recommendations
Recommended Diabetes Education Plan
Topic Number of Minutes Key Education Needed Vocational Rehabilitation
Healthy Eating
Being Active
Monitoring
Taking Medication
Healthy Coping
Problem Solving
VR2888 (02/23) Diabetes Self-Management Education Assessment Page 8 of 11
Reducing Risk
Total Minutes Recommended: Total Hours Recommended:
Total number of hours is the anticipated time training will take. A one hour post training assessment should be conducted at least 30 days after the final training session.
The Diabetes Education Plan described above will address the following cultural influences:
Race Gender Ethnicity Culture Religion/Spirituality Socioeconomic Status Disability Person/family-centered beliefs Language Health Beliefs Work culture
Equipment Recommendations
Blood Glucose monitoring?
Prodigy Voice Prodigy Auto code (for Spanish, French, or Arabic speaking customers only) Other meter: Other meter Recommendation:
Disability:
Number of additional test strips to include (200 is standard):
200 Lancets
Insulin Delivery Count a Dose Magniguide
Other Devices Blood Pressure Monitor: Medium Cuff Large Cuff Talking Body weight scale Talking Body weight scale Diabetes Socks: Size:
Medical ID Pill organizer Meal Measure
Other equipment or special needs (describe):
Describe customer’s commitment to use equipment above (if provided):
VR2888 (02/23) Diabetes Self-Management Education Assessment Page 9 of 11
Disability Services
Due to the customer’s disability, they have difficulty with the following which impacts their diabetes self-management:
Cooking skills: stovetop, microwave, oven, crock pot, George Foreman grill Adaptive kitchen tools, including timers Kitchen and meal organization, labeling, marking Following directions on recipes Grocery shopping, including identifying healthy foods and food freshness and purchasing diabetes management supplies
Record keeping (glucose results log, medication list, important phone numbers) Medication labeling, marking, identifying, and organizational techniques and methods Setting reminders for medication or other health activities Being active without vision (O&M) Being active due to disability (Recreation)
Additional comments regarding impact of disability and diabetes self-management:
Customer’s Learning Style
Instructional method recommended: Individualized training Group training Combination
Learning barriers: Auditory Visual Literacy or numeracy Decreased hand sensation Cognition/Memory Other (specify):
Highest level of education:
Primary language: English Spanish Other (specify):
Customer will work on this behavior change goal until our next visit (customer’s actions until next visit):
Observations, comments, and recommendations not covered previously:
Start time of visit: End time of visit:
Date of assessment: Total hours for assessment:
VR2888 (02/23) Diabetes Self-Management Education Assessment Page 10 of 11
Provider Signatures Diabetes Educator Signature (Required for all providers)
By signing below, I certify that:
• the above dates, times, and services are accurate;
• I personally facilitated all training, meeting all outcomes required for payment and documented the service, as prescribed in the VR-SFP and service authorization;
• Verification of the customer’s satisfaction and service delivery obtained as stated above;
• I maintain the staff qualifications required for a Diabetes Educator as described in the VR-SFP or
Service Authorization; and
• I signed my signature and entered the date below.
Typed or Printed name:
Signature: (See VR-SFP 3 on Signatures)
X
Date Signed:
Director (only required for Traditional-Bilateral Contractors) By signing below, I, the Director, certify that:
• I ensure that the services were provided by qualified staff, met all outcomes required for payment, and services were documented, as prescribed in the VR-SFP and service authorization;
• I maintain UNTWISE Director credential, as prescribed in VR-SFP;
• I signed my signature and entered the date below.
Typed or Printed name:
Signature: (See VR-SFP 3 Signatures)
X
Date Signed:
Select all that apply: UNTWISE Credentialed with ID:
VR3490-Waiver Proof Attached
VRS Use Only If any question below is answered no or if the report or supporting documentation is missing or incomplete, return the invoice to the provider with the VR3460. Make a case note to document the results of the review and the date VR3460 was sent to provider, when applicable.
Technical Review to Verify Provider Qualifications (Completed by any VR staff such as RA, CSC, VR Counselor)
Director’s Credential:
UNTWISE website or attached VR3490 verifies, for the dates of service, the director listed above:
maintained or waived the UNTWISE Director Credential did not hold a valid UNTWISE Director Credential
Verification of Service Delivery Technical Review (completed by any VR staff such as RA, CSC, VR Counselor) Verified that the report is accurately completed per form instructions Yes No Verified that the service(s) was provided within service date of SA and as stated in the VR Standards for Providers and/or the SA Yes No
When applicable, verify a copy of an approved VR3472 is attached to the report? NA Yes No
Verified that this individual session was held for two hours. Yes No Verified that the form was submitted to VRS within 35 days of completion. Yes No
VR2888 (02/23) Diabetes Self-Management Education Assessment Page 11 of 11
Verified that the appropriate fee(s) was invoiced Yes No Printed name of VR staff member making verification:
1. Date: 2. Date:
VR Counselor Review Verified that the form reports the information the Diabetes Educator captured during the initial assessment as well as their recommendations for equipment and training.
Yes No
By typing or printing your name, the VRC verifies:
• completion of the technical review,
• services provided met the customer’s individual needs,
• services provided met specifications in the VR-SFP and on the SA, and
• customer’s or legally authorized representative’s satisfaction with services received.
Approve to pay invoice Do not approve to pay invoice VR Counselor: Date:
| Diabetes Self-Management Education Assessment |
| Instructions |
| Customer Information |
| Customer Demographics |
| Support System |
| Diabetes History |
| Diabetes Self-Management Education Assessment |
| Vocational Rehabilitation (for VR customers only) |
| Healthy Eating (VR and OIB) |
| Being Active (VR and OIB) |
| Monitoring (VR and OIB) |
| Taking Medication (VR and OIB) |
| List of current medications |
| Healthy Coping (VR and OIB) |
| Problem Solving (VR and OIB) |
| Reducing Risk (VR and OIB) |
| Overall Recommendations |
| Recommended Diabetes Education Plan |
| Equipment Recommendations |
| Disability Services |
| Customer’s Learning Style |
| Provider Signatures |
| Diabetes Educator Signature (Required for all providers) |
| Director (only required for Traditional-Bilateral Contractors) |
| VRS Use Only |
| Technical Review to Verify Provider Qualifications (Completed by any VR staff such as RA, CSC, VR Counselor) |
| Director’s Credential: |
| Verification of Service Delivery |
| Technical Review (completed by any VR staff such as RA, CSC, VR Counselor) |
| VR Counselor Review |
| Customer name: |
| TWSVRS Case ID: |
| Referral date: |
| Counselor name: |
| Service authorization number: |
| Age: |
| Number in household including customer: |
| Physician name specialty and contact information handling Diabetes Management: |
| Primary and secondary insurance if applicable: |
| If no enter explanation andor comments: |
| Community resources used by customer: |
| Primary support person and relationship: |
| What is the customers previous occupation: |
| What is the customers current occupational goal: |
| Comments and recommendations regarding Vocational Rehabilitation: |
| Customers meals are well spaced but needs information about timing and medication: Off |
| Comments or recommendations regarding healthy eating: |
| Customer should be able to participate in exercise: Off |
| What activities has the customer enjoyed in the past: |
| What activities would the customer like to do: |
| Comments or recommendations regarding being active: |
| Current meter: |
| Frequency of testing: |
| Customer can verbalize individual blood sugar goals: Off |
| Customer can verbalize blood pressure goals: Off |
| Customer can verbalize Hemoglobin A1c goals: Off |
| Customer needs training on monitoring goals: Off |
| Customer does not believe the results are useful: Off |
| Customer is unable to perform tasks independently: Off |
| Customer currently monitors appropriately: Off |
| Customer uses results in day to day diabetes management: Off |
| Comments or recommendations regarding Monitoring: |
| List any allergies food or drug: |
| Support person assists in insulin administration: Off |
| Customer does not take insulin or other injectable: Off |
| Customer verbalizes how to draw and administer appropriate storage and travel: Off |
| Customer verbalizes appropriate injection sites and proper site rotation: Off |
| Customer verbalizes onset peak and duration: Off |
| Customer needs full training on insulin: Off |
| Customer has an organized method for storing and managing medications: Off |
| Customer needs instruction on storing and managing medication: Off |
| Customer uses vitamins and other alternative medicine describe in comments: Off |
| Customer is able to manage other medications: Off |
| Customer needs training on medications: Off |
| Comments and recommendation regarding taking medication: |
| Customer is in charge of the diabetes: Off |
| Customer tries to manage it but feels there is not much he or she can do: Off |
| Diabetes is in charge of customer: Off |
| Customer doesnt like it but does the selfcare tasks anyway: Off |
| Family and friends are physically and emotionally available to help customer: Off |
| Family and friends help customer in ways that the customer is resistant to receive: Off |
| There are family and friends available but they have given up on helping customer: Off |
| Customer has no support system: Off |
| Customer feels hopeful about the future and diabetes is manageable: Off |
| Customer has minor symptoms such as occasional blues fearfulness and sleeplessness: Off |
| Customer is currently depressed and finds it difficult to deal with diabetes and other health issues: Off |
| Customer is not familiar with stress management techniques: Off |
| Customer declines assistance with healthy coping: Off |
| Comments and recommendations regarding healthy coping: |
| Customer can verbalize a plan should hypoglycemia happen at work: Off |
| Customer needs training on hypoglycemia: Off |
| Customer can verbalize a plan should hyperglycemia happen at work: Off |
| Customer needs training on hyperglycemia: Off |
| Customer needs training on foot and skin care: Off |
| Comments and recommendations regarding problem solving: |
| Customer smokes: Off |
| Customer has participated in risky behaviors in the past and needs education about effect on health: Off |
| Customer does not smoke drink excessively or have problems with drugs: Off |
| Customer has problems with drugs or excessive alcohol usage: Off |
| Customer needs training on risks of diabetes mismanagement: Off |
| Customer does not participate in scheduled healthcare describe in comments: Off |
| Comments and recommendations regarding reducing risk: |
| Other equipment or special needs describe: |
| Describe customers commitment to use equipment above if provided: |
| Additional comments regarding impact of disability and diabetes selfmanagement: |
| Highest level of education: |
| Customer will work on this behavior change goal until our next visit customers actions until next visit: |
| Observations comments and recommendations not covered previously: |
| Start time of visit: |
| End time of visit: |
| Date of assessment: |
| Total hours for assessment: |
| VR Counselor: |
| Customer Sex: Off |
| Customer Marital Status: Off |
| Can customer meet diabetes related expenses: Off |
| Does the customer have disability assistance available when needed: Off |
| Does the customer currently receive home health services: Off |
| Does the customer belong to and or attend any diabetes or disability support groups: Off |
| Has the customer participated in formal diabetes education in the past: Off |
| Does the customer understand the pathophsiology of diabetes: Off |
| Has the customer been to the emergency room or hospitalized in the last six months: Off |
| Has the customer ever missed work or school because of diabetes: Off |
| Does the customer know his or her most recent A1c: Off |
| Customers learning style primary language: Off |
| Director credential UNTWISE wesbite or attached VR 3490 verifies for the dates of service the director listed above: Off |
| Telephone number area code 3 digits: |
| Telephone number 7 digits: |
| Diabetes Type: Off |
| Diabetes History duration years: |
| If yes when has the customer participated in formal diabetes education in the past: |
| Customer risk factor Family history of diabetes: Off |
| Customer risk factor Over age 45: Off |
| Customer risk factor Unhealthy alcohol consumption: Off |
| Customer risk factor Smoking: Off |
| Customer risk factor High blood pressure: Off |
| Customer risk factor Obesity: Off |
| Customer height: |
| Customer has or at risk for Foot problems: Off |
| Customer has or at risk for Neuropathy: Off |
| Customer has or at risk for Renal problems: Off |
| Customer has or at risk for Cardiovascular problems: Off |
| Customer has or at risk for Other complications describe: Off |
| Description of Customer has or at risk for other complications: |
| Description of Customer visit to emergency room or hospitalization in the last 6 months: |
| Customer needs frequent breaks for frequent snacks and meals: Off |
| Customer needs frequent breaks for monitoring: Off |
| Customer needs frequent breaks for medication: Off |
| Customer does not need frequent breaks for selfcare at work: Off |
| Customer is able to monitor blood sugar independently with audio meter: Off |
| Customer is able to monitor blood sugar independently with nonaudio meter: Off |
| Customer is not able to monitor blood sugar independently but wants training to be independent: Off |
| Customer is unwilling or unable to monitor independently: Off |
| Customer understands diabetesrelated impact on employment: Off |
| Customer does not understand diabetesrelated impact on employment but is ready to learn: Off |
| Customer does not understand diabetesrelated impact on employment and is unwilling or unable to learn: Off |
| Customer understands the effect of Carbohydrates on blood sugar: Off |
| Customer understands the effect of Proteins on blood sugar: Off |
| Customer understands the effects of Fats on blood sugar: Off |
| Customer does not understand the effect of any of these foods on blood sugar Customer needs full education on the macronutrients: Off |
| Customer can verbalize appropriate portion sizes for Carbohydrates: Off |
| Customer can verbalize appropriate portion sizes for Proteins: Off |
| Customer can verbalize appropriate portion sizes for Fats: Off |
| Customer cannot verbalize appropriate portion sizes Customer needs training on portion sizing: Off |
| Customer is able to verbalize healthy meal options for Breakfast: Off |
| Customer is able to verbalize healthy meal options for Lunch and Dinner: Off |
| Customer is able to verbalize healthy meal options for Snacks: Off |
| Customer cannot verbalize healthy meal options Customer needs training on meal options: Off |
| Customer needs full education on timing of foods and medications: Off |
| Customer follows meal and medication plan at least 80 of the time: Off |
| Customer has concerns regarding Food preferences: Off |
| Customer has concerns regarding Religious or cultural considerations: Off |
| Customer has concerns regarding Cost and availability of healthy foods: Off |
| Customer has no concerns regarding healthy eating: Off |
| Customer needs education on Restaurants Alcohol and fast food: Off |
| Customer needs education on Ability to prepare healthy foods: Off |
| Customer needs education on Dietary restrictions related to health status low fat low salt renal etc: Off |
| Customer does not need education on any of these eating habits: Off |
| Hypoglycemia or Hyperglycemia limit customer ability to exercise: Off |
| Physical disability limits customer ability to exercise: Off |
| Motivation limits customer ability to exercise: Off |
| Customer has Treadmill stationary bike or other cardiovascular equipment: Off |
| Customer has Weights: Off |
| Customer has Workout videos or games: Off |
| Customer has no resources for exercise: Off |
| Customer current exercise level None: Off |
| Customer current exercise level Seldom Customer exercises less than one hour per week: Off |
| Customer current exercise level Occasionally Customer exercises two to four hours per week: Off |
| Customer current exercise level Regular Customer exercises five or more hours per week: Off |
| Customer has an audio meter and supplies: Off |
| Customer has a meter and supplies without audio features: Off |
| Customer needs an audio meter and supplies: Off |
| Customer wants a meter and supplies without audio features: Off |
| Current blood glucose reading timing: Off |
| Date of current blood glucose reading: |
| Time of current blood glucose reading: |
| Result of current blood glucose reading: |
| Customer most recent A1c result: |
| Customer understands how to use the meter and get a drop of blood to the test strip: Off |
| Customer shows willingness to monitor blood sugar: Off |
| Customer needs education or motivation to monitor: Off |
| Monitoring is not recommended for this customer: Off |
| Customer monitors Weight: Off |
| Customer monitors Ketones: Off |
| Customer monitors Blood pressure: Off |
| Customer monitors none of these other health metrics: Off |
| Customer currently checks blood pressure at the Doctors office: Off |
| Customer currently checks blood pressure at the Pharmacy or grocery: Off |
| Customer currently checks blood pressure at Home: Off |
| Customer does not currently check blood pressure: Off |
| Cost and availability of supplies keep the customer from monitoring: Off |
| Customer is able to Retrieve values from the meters memory andor keep a record of results of blood sugars and other data: Off |
| Customer is able to Dispose of lancets and syringes appropriately: Off |
| Customer is able to Adjust his or her diet medication and activity based on results: Off |
| Current Medication 1: |
| Current Medication 2: |
| Current Medication 3: |
| Current Medication 4: |
| Current Medication 5: |
| Current Medication 6: |
| Current Medication 7: |
| Current Medication 8: |
| Current Medication 9: |
| Current Medication 10: |
| Current Medication 11: |
| Current Medication 12: |
| Dosage of Current Medication 1: |
| Dosage of Current Medication 2: |
| Dosage of Current Medication 3: |
| Dosage of Current Medication 4: |
| Dosage of Current Medication 5: |
| Dosage of Current Medication 6: |
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| Dosage of Current Medication 9: |
| Dosage of Current Medication 10: |
| Dosage of Current Medication 11: |
| Dosage of Current Medication 12: |
| Frequency of Current Medication 1: |
| Frequency of Current Medication 2: |
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| Frequency of Current Medication 4: |
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| Frequency of Current Medication 8: |
| Frequency of Current Medication 9: |
| Frequency of Current Medication 10: |
| Frequency of Current Medication 11: |
| Frequency of Current Medication 12: |
| Condition treated by Current Medication 1: |
| Condition treated by Current Medication 2: |
| Condition treated by Current Medication 3: |
| Condition treated by Current Medication 4: |
| Condition treated by Current Medication 5: |
| Condition treated by Current Medication 6: |
| Condition treated by Current Medication 7: |
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| Condition treated by Current Medication 10: |
| Condition treated by Current Medication 11: |
| Condition treated by Current Medication 12: |
| Insulin or injectable medication is drawn and administered Independently without assistive devices: Off |
| Insulin or injectable medication is drawn and administered Independently using assistive device describe in comments: Off |
| Customer Knows the purpose of his or her medications and how it works: Off |
| Customer Takes medications as recommended: Off |
| Customer Knows when to notify the doctor and knows what to ask when prescribed a new medication: Off |
| Customer is okay right now but has been depressed in the past and is concerned about depression returning: Off |
| Customer uses prayer deep breathing exercises affirmations etc to manage stress: Off |
| Customer has a strong support system to manage stress: Off |
| Customer uses exercise andor other active techniques to manage stress: Off |
| Customer would like help with Books audio website and community resource recommendations: Off |
| Customer would like Help with diabetes police and other caregiver concerns: Off |
| Customer would like Help dealing with depression and diabetes issues: Off |
| Customer can verbalize the signs and symptoms of hypoglycemia and his or her personal response: Off |
| Customer can verbalize appropriate treatment for hypoglycemia: Off |
| Customer can verbalize the signs and symptoms of hyperglycemia and his or her personal response_2: Off |
| Customer can verbalize appropriate treatment for hyperglycemia: Off |
| Sick Days Customer understands the importance of monitoring taking medication eating and staying hydrated: Off |
| Sick Days Customer can verbalize when to call the doctor: Off |
| Sick Days Customer needs education on managing sick days: Off |
| Customer is able to perform a foot examination and verbalize appropriate skin and wound care: Off |
| Customer is able to verbalize the importance of wearing medical identification: Off |
| Customer is able to choose appropriate clothing shoes and socks that are not binding: Off |
| Customer understands the consequence of diabetes mismanagement Cardiovascular risk including stroke: Off |
| Customer understands the consequence of diabetes mismanagement Neuropathy and amputation risks: Off |
| Customer understands the consequence of diabetes mismanagement Kidney disease risk: Off |
| Customer understands the consequence of diabetes mismanagement Dental disease risk: Off |
| Customer participates in regular doctors visits including a discussion of laboratory values for diabetes risk factors and immunizations: Off |
| Sick Days Customer has a sick day kit put together with cold medicines and other things needed to manage when he or she is sick: Off |
| Customer participates in annual eye exams minimum: Off |
| Customer participates in annual dental exams: Off |
| Customer participates in regular foot exams by a professional: Off |
| Vocational Rehabilitation Education Plan Number of Minutes: |
| Healthy Eating Education Plan Number of Minutes: |
| Being Active Education Plan Number of Minutes: |
| Monitoring Education Plan Number of Minutes: |
| Taking Medication Education Plan Number of Minutes: |
| Healthy Coping Education Plan Number of Minutes: |
| Problem Solving Education Plan Number of Minutes: |
| Reducing Risk Education Plan Number of Minutes: |
| Vocational Rehabilitation Key Education Needed: |
| Healthy Eating Key Education Needed: |
| Being Active Key Education Needed: |
| Monitoring Key Education Needed: |
| Taking Medication Key Education Needed: |
| Healthy Coping Key Education Needed: |
| Problem Solving Key Education Needed: |
| Reducing Risk Key Education Needed: |
| Total Minutes of Diabetes Education Recommended: |
| Total Hours of Diabetes Education Recommended: |
| The Diabetes Education Plan will address Race: Off |
| The Diabetes Education Plan will address Gender: Off |
| The Diabetes Education Plan will address Ethnicity: Off |
| The Diabetes Education Plan will address Culture: Off |
| The Diabetes Education Plan will address ReligionSpirituality: Off |
| The Diabetes Education Plan will address Socioeconomic Status: Off |
| The Diabetes Education Plan will address Disability: Off |
| The Diabetes Education Plan will address Personfamilycentered beliefs: Off |
| The Diabetes Education Plan will address Language: Off |
| The Diabetes Education Plan will address Health Beliefs: Off |
| The Diabetes Education Plan will address Work culture: Off |
| Prodigy Voice recommended for blood glucose monitoring: Off |
| Prodigy Auto code for Spanish French or Arabic speaking customers only recommended for blood glucose monitoring: Off |
| Other meter recommended for blood glucose monitoring: Off |
| 200 Lancets recommended for blood glucose monitoring: Off |
| Other blood glucose monitoring meter recommended: |
| Equipment Recommendation Disability: |
| Number of additional test strips to include 200 is standard: |
| Count a Dose recommended for Insulin Delivery: Off |
| Magniguide recommended for Insulin Delivery: Off |
| Blood Pressure Monitor recommended: Off |
| Body weight scale recommended: Off |
| Talking Body weight scale recommended: Off |
| Diabetes Socks recommended: Off |
| Medical ID recommended: Off |
| Pill organizer recommended: Off |
| Meal Measure recommended: Off |
| Medium Cuff blood pressure monitor recommended: Off |
| Large Cuff blood pressure monitor recommended: Off |
| Talking blood pressure monitor recommended: Off |
| Recommended diabetes socks size: |
| Customer has difficulty with Cooking skills stovetop microwave oven crock pot George Foreman grill: Off |
| Customer has difficulty with Adaptive kitchen tools including timers: Off |
| Customer has difficulty with Kitchen and meal organization labeling marking: Off |
| Customer has difficulty with Following directions on recipes: Off |
| Customer has difficulty with Grocery shopping including identifying healthy foods and food freshness and purchasing diabetes management supplies: Off |
| Customer has difficulty with Record keeping glucose results log medication list important phone numbers: Off |
| Customer has difficulty with Medication labeling marking identifying and organizational techniques and methods: Off |
| Customer has difficulty with Setting reminders for medication or other health activities: Off |
| Customer has difficulty with Being active without vision OM: Off |
| Customer has difficulty with Being active due to disability Recreation: Off |
| Instructional method recommended: Off |
| Auditory learning barrier: Off |
| Visual learning barrier: Off |
| Literacy or numeracy learning barrier: Off |
| Decreased hand sensation learning barrier: Off |
| CognitionMemory learning barrier: Off |
| Other learning barrier specify: Off |
| Description of other learning barrier: |
| Description of other primary language: |
| Diabetes Educator Typed or Printed name: |
| Date Signed by Diabetes Educator: |
| Director Typed or Printed name: |
| Date Signed by Director: |
| Director UNTWISE Credentialed with ID: Off |
| Director UNTWISE Credential ID: |
| Director VR3490Waiver Proof Attached: Off |
| VR Staff Verified that the report is accurately completed per form instructions: Off |
| VR Staff verified that the service was provided within service date of SA as stated in the VR Standards for Providers andor the SA: Off |
| When applicable VR Staff verified a copy of an approved VR3472 is attached to the report: Off |
| VR Staff verified that this individual session was held for two hours: Off |
| VR Staff verified that the form was submitted to VRS within 35 days of completion: Off |
| VR Staff verified that the appropriate fee was invoiced: Off |
| Printed name of first VR staff member making verification: |
| Printed name of second VR staff member making verification: |
| First VR staff member Date: |
| Second VR staff member Date: |
| VR Counselor verified that the form reports the information the Diabetes Educator captured during the initial assessment as well as their recommendations for equipment and training: Off |
| VR Counslor approval to pay invoice: Off |
| VR Counselor Date: |
| Customer weight in pounds: |
| Yes Customer is comfortable sharing information about diabetes and managing it in front of coworkers: Off |
| Yes Customer understands the importance of discussing diabetes with coworkers but wants to settle in before beginning the conversation: Off |
| No Customer needs instruction on what to discuss with coworkers and how: Off |
| No Customer feels that diabetes is a personal matter and none of the coworkers business: Off |
| Yes Customer knows how to respond to the results regarding adjustments in medications: Off |
| Yes Customer knows how to respond to the results regarding treatment of hypoglycemia and hyperglycemia and seeking medical help: Off |
| Yes Customer knows how to respond to the results regarding adjustments in food: Off |
| No Customer does not know how to respond to the results: Off |
File details come from the government source that posted it. Updated .