Essential Documentation Requirements for Outpatient Diabetes Care Visits

Patient Identification & Administrative Data

Initial Visit – Core History Elements

Follow‑Up Visit – Updated History Elements

Annual Visit – Comprehensive Assessment

Physical Examination – Required at Every Initial Visit

Annual Comprehensive Foot Examination

Assessment & Plan Section – Core Content

Review of Systems (When Relevant)

Social Determinants & Psychosocial Screening

Documentation Pitfalls to Avoid