Diabetes referral form

Diabetes Specialist Nurse (DSN) Referral Form (Adult)
1. To be completed in conjunction with the diabetes nurse specialist pathway (See Over)
2. Patients can not be seen if this form has not been completed, unless a referral letter has been written 3. To be sent to DSN or retained with patients notes if the referral is phoned / faxed NB Newly diagnosed patients with Type 2 diabetes on Diet / Metformin alone should be given a newly
diagnosed education pack and be referred to primary care to be seen by G/P and practice nurse
Primary reason for Referral
Inpatients starting insulin secretagogues
Only following a medical review of
current treatment & dosages

Current Medications
Presenting Problem / Complicating Factors
Additional Information as needed
Diabetes Specialist Nurse (DSN) Patient Pathway (Adult)
Criteria for Referral
Confirmed Diagnosis of Diabetes Mellitus (WHO Criteria) Impaired Glucose Tolerance in Pregnancy (see separate protocol) Verbal Consent from Patient to contact Diabetes Service
Patient identified as needing advice/support for:-
Complete referral form to
DSN for area
Inpatients commencing secretagogue (e.g. Gliclazide) Insulin initiation (Type 2 changing to insulin from tablets) Declining glycaemic control where primary intervention
and medical review has been unsuccessful. Multiple
diabetes related complications / life style strategies Criteria not met:
Diabetes and Pregnancy / Adolescent transitional care Diabetes Specialist Nurse Intervention:
Clinic appointment/telephone contact/ward visit or home visit (in exceptional circumstances) Assessment of needs:
Discharge to
primary care or
original referrer
Planned long term follow-up for some patients Guidance Notes
1. Newly diagnosed patients with Type 2 Diabetes on diet or Metformin alone should be given a newly diagnosed education pack and referred to their primary care team (G/P and Practice Nurse) for initialeducation. Within the pack is an invitation for patients to attend a group educational session with the DSN, Dietician and Podiatrist. Patients should be encouraged to attend these to complete their education.
2. Newly diagnosed education packs are available from Godolphin Ward - RCH ≠2010 and the Diabetes Education Centre (01872 254560) RCHT, GP surgeries and Health Promotion Centre (Pool 01209 313218) 3. Diabetes What Can I Eat? Leaflet is a available from the Diabetes Centre (01872 254560) or publications (01872 254668) and is also in the newly diagnosed education pack.
4. It is expected that all registered nurses will be able to safely teach subcutaneous injection technique, home blood glucose monitoring, and give basic dietary advice for people with newly diagnosed orestablished diabetes treated with diet or hypoglycaemic agents alone.

Source: http://diabetes-service.co.uk/referrals/documents/16.pdf

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