Care Plans
Sarah Johnson · MRN P-2024-042
Diabetes Management — Type 2
Goal
Achieve and maintain HbA1c below 7.5% through medication adherence, dietary modification, and regular glucose monitoring.
Key Indicators
8.2%
HbA1c (Target <7.5%)
148
Fasting Glucose mg/dL
95%
Medication Adherence
Action Items
- Daily fasting glucose monitoring — log in patient portal
- Metformin 1000mg twice daily with meals
- Dietary consult scheduled — low glycemic index plan
- A1C lab draw — overdue, schedule within 2 weeks
- Ophthalmology referral for annual diabetic eye exam
Progress60% (3 of 5)
Hypertension Control
Goal
Reduce systolic BP below 130 mmHg and diastolic below 80 mmHg through medication optimization and lifestyle modifications.
Key Indicators
142/88
BP (Target <130/80)
78
Heart Rate bpm
92%
Medication Adherence
Action Items
- BP monitoring twice daily — morning and evening
- Lisinopril 10mg daily — titrate per cardiologist
- Sodium restriction: <1500mg per day — dietary coaching
- Cardiology follow-up scheduled Apr 14, 2026
Progress50% (2 of 4)
Weight Management Program
Goal
Achieve 5–10% weight reduction (target 168–178 lbs) through caloric restriction, increased physical activity, and behavioral counseling.
Action Items
- Weekly weigh-in logged via Bluetooth scale
- Registered with telehealth dietitian
- 30-min light walking 4x/week (cleared by cardiology)
- Behavioral health check-in monthly
- Jardiance refill — dual benefit for glucose and weight
Progress40% (2 of 5)
Fall Prevention Protocol
Goal
Reduce fall risk score from HIGH (Morse Scale 55) to MODERATE through physical therapy, home safety assessment, and medication review.
Action Items
- Falls risk assessment completed — Morse Scale: 55 (High)
- Physical therapy referral — awaiting insurance auth
- Home safety visit scheduled
- Medication review for fall-risk drugs (furosemide, carvedilol)
Progress25% (1 of 4)