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Diabetes - Follow Up of Patients with Established Diabetes

Diabetes - Follow up of Patients with Established Diabetes

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Once diabetes has been diagnosed and an initial treatment plan drawn up there is a need to enter into regular, planned follow up. 

The aims of diabetes follow up are:

To deal with any current problems relating to control or other issues

To optimise control of blood glucose, blood pressure and lipids

Surveillance for complications of diabetes

Management of known complications

Ongoing updating on current diabetes education

Motivation and empowerment around self management
Diabetes UK have produced a list of 15 Care essentials for those with diabetes

Learn More - Diabetes UK 15 Healthcare Essentials

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Annual Review


The need for regular surveillance for complications and for review of glycaemic control has lead to the concept of the annual review in diabetes care: this is a convenient way of ensuring that the various elements which need reviewing are completed and are not missed out. 


The purpose of the review is to guide management and highlight necessary change: the collection of the data is to allow this to be done effectively.

  The key elements of any review are to:
  Measure and Examine

Discuss and Educate

Set Targets and Manage Actively

Agree a Review

  Measure & Examine:





Weight / BMI





Learn More

Waist circumference

Learn More



Eyes (usually done as part of Retinal Screening Service)

Learn More


Blood pressure

Learn More



Injection sites (if on insulin)



Haemoglobin A1C

Learn More





Serum Creatinine / eGFR

Learn More





Lipid profile

Learn More






Learn More




  Discuss and Educate:

Issues raised by patient


Review progress towards previously agreed goals


Current control and concordance with current medication


Diet and exercise


Explain test results and examination findings


Smoking / alcohol (if relevant)


Pre-conception / Contraception (if relevant)

  Educational update
  Set Targets and Manage Actively:

Assess findings of annual review against evidence base and personal agenda


Prioritise and plan: agree and record goals for ongoing care.


Agree medication (if relevant)

  Agree a Review:

Achieving targets may need repeated titration steps.


The goals set will determine the nature and timing of the next planned contact.

  Arrange next contact / appointment

Refer to specialist care if appropriate.

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Useful External Links & Resources

PDF File

Diabetes UK 15 Healthcare Essentials
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