Process - Physician - Fraser Health Authority

Client name: _______________________________METABOLIC MONITORING FORMMENTAL HEALTH AND SUBSTANCE USE (MHSU)PHN: _____________________________________DOB (dd/mm/yy): ________________ Age: _______Gender: Male Female Unknown/undifferen.Psychiatrist: _______________________________MHXX104076B Rev: Apr. 11/11Page: 2 of 3GPNo GP, refer to:METABOLIC MONITORINGRisk factor Defining level BaselineDateDateDateDateDateInitialsInitialsInitialsInitialsInitialsInitialsTest date (dd/mm/yy) Moderate riskWeight(kg / lbs) Waistcircumference Bloodpressure Triglycerides FastingHDLcholesterol≥ 5% increasefrom baselineM > 102cm/40inF > 88cm/35inTx At risk Tx At risk Tx At risk Tx At risk Tx At risk Tx At riskAt risk At risk At risk At risk At risk At risk> 140/90, or> 130/80 ifdiabetes /disease* Tx At risk Tx At risk Tx At risk Tx At risk Tx At risk Tx At risk> 1.7 mmol/LMF≤ 1.03mmol/L≤ 1.29mmol/LTx At risk Tx At risk Tx At risk Tx At risk Tx At risk Tx At riskTx At risk Tx At risk Tx At risk Tx At risk Tx At risk Tx At riskHigh risk FastingglucoseMetSdiagnosisPsychotropicmedicationsDiabetes-DKA checklist> 5.6 mmol/L≥ of factorsNew start/changein last 3 monthsSigns andsymptomsTx At risk Tx At risk Tx At risk Tx At risk Tx At risk Tx At riskMetS MetS MetS MetS MetS MetSNewChangeAt riskNo S&SNewChangeAt riskNo S&SNewChangeAt riskNo S&SNewChangeAt riskNo S&SFollow up (as per FH MHSU guidelines – risk levels and associated monitoring frequencies)Current risk(low / moderate / high)Repeat PHYSICAL MEASURESin X months?Repeat LABS in X months?NewChangeAt riskNo S&SNewChangeAt riskNo S&SReviewed with physician /physician confirmation (signature)Referred to GP / primary careprovider (Y/ N)DKA: diabetic ketoacidosis; Initials: sign initials; MetS: metabolic syndrome; S&S: Signs and symptoms; Tx: Treatment (meds for risk factor)* if client has diabetes, renal disease or other target organ damage (i.e., cerebrovascular disease, coronary heart disease (CHD), leftventricular hypertrophy (LVH), chronic kidney disease (CKD), peripheral vascular disease and hypertensive retinopathy.Next page