Checklist Interview.xlsx

	A	B	C	D	E
1	Checklist Interview( can use soft copy or hard copy)
2
3	Nama Pesakit	norizan sulaiman
4	RN	7533
5	Visit Num	2
6	Date	23/5/2024
7	Pharmacist	Norida
8
9	1) Baseline assessment	Items			Profile Patient
10	TRUE	Social/family history (parents/siblings diabetic?)			no family history of dm
11	TRUE	Occupational history (housework/shift work/office work/student			ex-penoreh getah
12	TRUE	Diet and lifestyle - meals for breakfast/lunch/dinner/supper/snacking - exercise/sedentary/smoking /alcohol			gardening bf: nasi 3-4 sup/ lauk/ sayur/ milo kosong lunch : nasi segegam lebih/lauk/air suam malam: biskut / air suam tambah air gula (sudu kecik)
13
14
15	2) Disease knowledge assessment/therapeutic goals (Refer module 1)	Items			Profile Patient
16	FALSE	Apa itu kencing manis?
17		- guna analogy insulin as kunci sel - symptoms - complications (module 4)
18	FALSE	Bacaan gula cantik berapa?			11.2 - 10.8 (post 2 hr) 11.4%
19		fasting/pre-meal	4.4-7.0mmol/l
20		post meal	4.4-8.5mmol/l
21		hbaic (indivudualize)
22		< 6.5%	6.6-7.0%	7.1-8.0%
23		newly diagnosed	all others	elderly
24		younger age		presence of comorbidity
25		healthier (no complications)		high risk for hypo
26		low risk of hypo		hypo unawareness
27				short life expectancy
28	FALSE	LP
29		TG	less than or equal to 1.7
30		HDL	male > 1.0mmmol/l femlae >1.2 mmol/l
31		LDL	less than or equal to 2.6mmol/l
32	FALSE	BP	130-139/70-79mmhg
33	FALSE	Weight Management	if overweight, or obese aim for up to 10% weight loss in 6 month (module 3)		64kg
34	TRUE	Exercise	150minutes/week (module 3)		gardening
35
36
37	3) Medication Knowledge (refer module 2)	Items			Patient Profile
38	FALSE	Insulin use (emphasize for the need of insulin)
39	FALSE	Insulin injection technique (refer checklist injection tecnique)
40	FALSE	OGLDs / other medications
41	TRUE	signs and symptoms hypoglycemia & management			never experience hypo, but knowledgeable about symptoms, always standby gula2,
42	TRUE	medication adherence (mymaat)- module in phis
43	TRUE	assess understanding of medications(dfit score, module in phis)			aspirin still taking prn even after counseled on last visit
44	FALSE	discuss changes in medication (decrease/increase dose/change meds/etc) (if any)
45
46	3) SMBG (module 2)	FALSE	why
47		FALSE	when
48		FALSE	how
49		FALSE	review/discuss patient adjustment dose (if any)		smbg readings didnt. last reading was on wedensday 15/5/24, fbs 8.5, to take reading on wednesday. pt agreed and to adjust dose according
50		TRUE	BSP/diary smbg		given smbg diary
51
52	4) Discussion of any adverse effects with patient (oral medications/insulin)	FALSE
53
54	5) Review and set individualised patient targets	TRUE
55
56	6) Other counseling (if any)	FALSE
57
58	7) Set new appointment for pharmacist review	TRUE	23/6/2024
59
60	8) Mengepilkan BMS bersama BSP Form (wajib bagi pesakit insulin, optional bagi pesakit oral medication)	FALSE
61
62	Checklist Injection Tecnique				Patient Profile
63	FALSE	Roll of insulin between palm (pre-mixed/long acting insulin)
64	FALSE	Priming
65	FALSE	Press the injection button until figure in the dose window return 0
66	TRUE	hold the needle for at least 10 seconds			didn't do
67	FALSE	Unscrew the needle, replace the pen cap
68	FALSE	administration time
69		site of injection
70	TRUE	needle use/frequency needle change/needle disposal			once a week. adhered to recommendation from previous visit
71	FALSE	storage and expiry
72	FALSE	important of insulin injection and adherence
73
74
75	Nama Pesakit
76	RN
77	Visit Num
78	Date
79	Pharmacist
80
81	1) Baseline assessment	Items			Profile Patient
82		Social/family history (parents/siblings diabetic?)
83		Occupational history (housework/shift work/office work/student
84		Diet and lifestyle - meals for breakfast/lunch/dinner/supper/snacking - exercise/sedentary/smoking /alcohol
85
86
87	2) Disease knowledge assessment/therapeutic goals (Refer module 1)	Items			Profile Patient
88		Apa itu kencing manis?
89		- guna analogy insulin as kunci sel - symptoms - complications (module 4)
90		Bacaan gula cantik berapa?
91		fasting/pre-meal	4.4-7.0mmol/l
92		post meal	4.4-8.5mmol/l
93		hbaic (indivudualize)
94		< 6.5%	6.6-7.0%	7.1-8.0%
95		newly diagnosed	all others	elderly
96		younger age		presence of comorbidity
97		healthier (no complications)		high risk for hypo
98		low risk of hypo		hypo unawareness
99				short life expectancy
100		LP (1st visit optional)