Whole Visit: A Diabetes Follow-Up

In practice

The patient checks in for a scheduled diabetes visit. The medical assistant confirms her identity and insurance and rooms her. When asked about medications, the patient names her diabetes medicines and, when asked specifically, a supplement she started last month. She records both. During the history, the patient mentions a sore on her foot that has not healed. The medical assistant records it in the patient's words and tells the provider before the exam, knowing that slow-healing sores matter in diabetes. The provider orders a fingerstick glucose and a blood draw for laboratory tests. The medical assistant runs the fingerstick with a calibrated meter, wiping away the first drop and not squeezing the finger, and records the result with the time. For the venipuncture, she chooses the tubes the tests need, collects them in the order of draw, and labels each at the point of collection. After the provider examines the foot and orders a wound culture, she collects it from the cleanest tissue after irrigation, as ordered. At checkout, she schedules the follow-up the provider asked for and reinforces the foot-care instructions, using teach-back. The visit is coded from the documentation, including the diabetes as a condition affecting care.