Diabetes Entry by Medical History

To enter an initial diagnosis of diabetes, or for subsequent monitoring, use Read Term Add or History Add to make a diabetic entry:

1. First select a patient and start a consultation.
2. Using Read Term Add, or Medical History-Add, in Read Term for Characteristic, type in DIABETES and press F3, for a diabetic list for selection. Alternatively, for an entry of diabetes mellitus, type in #C10. Useful Read terms include (their keywords are in italics):
   • C108 Insulin dependent diabetes (dependent, insulin)
   • C108.12 Type 1 diabetes mellitus (type)
   • C109.12 Type 2 diabetes mellitus (type)
   • C109 Non-insulin dependent diabetes (niddm)
   • C10 Diabetes mellitus (diabetes, dm, mellitus)
   • C106 Diabetes mellitus with neuropathy (diabetes, neurologic)
   • Or for monitoring:
   • 66AR Diabetes Management plan given (diabetes, management, plan)
   • 6872 Diabetes mellitus screen (diabetes)
   • 9NM0 Attending diabetes clinic (diabetes)
   • 9OL Diabetes monitoring admin.(diabetes)
   • 8H7f Referral to diabetic nurse (diabetes)
3. See Medical History for help with the other fields: Type of Characteristic, Episode Type, Priority, Numerics, End Date, free text Comment, and Recall.
4. When you click on OK, and if this is an initial entry of diabetes, you will be asked if you want to add this patient to the Chronic Disease Register for Diabetes or Diabetes Annual Check. Answer Yes if relevant.
5. The Chronic Disease Register - Diabetes screen displays (this screen can also be reached from the Add menu, selecting Chronic Disease Management - Diabetes Register. Click on the Health Promotion icon to record an intervention (see below). Click on the Recall or Notes icons as required. Click OK to accept the entry.

In this section Diabetes and Health Promotion