The Quick Guide to Diabetes SOAP Note Example

Diabetes management generates more documentation requirements than almost any other chronic condition.

Between quality measures, medication prior authorizations, screening protocols, and complication monitoring, a single diabetes visit can easily generate 30+ minutes of documentation work.

I've seen primary care physicians stay until 8 PM just catching up on diabetes notes.

The frustrating part? Most of that documentation time isn't spent on clinical thinking—it's spent remembering which specific elements insurance companies and quality programs require.

Did you document foot exam findings? Medication adherence barriers? Smoking status? Depression screening? Eye exam scheduling? Statin therapy rationale?

Miss any one of these elements and your note might fail a quality audit, even though you provided excellent clinical care.

This is exactly why SOAP Notes Doctor exists—to capture comprehensive diabetes documentation without the administrative burden.

Let me show you what actually matters in diabetes SOAP notes and how to document efficiently.

Why Diabetes Documentation Is Uniquely Complex

Most chronic conditions require straightforward monitoring: check the relevant numbers, adjust medications, ensure compliance.

Diabetes requires comprehensive documentation across multiple organ systems, preventive services, and behavioral factors simultaneously.

Here's what makes diabetes documentation different:

Quality measure programs (HEDIS, Medicare Stars, PCMH) track multiple diabetes metrics: HbA1c control, blood pressure control, statin use, ACE/ARB use, eye exams, foot exams, nephropathy screening, and more.

Prior authorization requirements for newer diabetes medications demand documented trials of metformin, sulfonylureas, and often long-acting insulin before approving GLP-1 agonists or SGLT2 inhibitors.

Complication screening protocols require annual documentation of diabetic foot exams, retinopathy screening, nephropathy assessment, and cardiovascular risk evaluation.

Patient education documentation must cover diet, exercise, glucose monitoring, hypoglycemia recognition, sick day management, and medication administration techniques.

Risk stratification influences treatment targets, with different HbA1c goals for elderly patients, those with hypoglycemia history, or limited life expectancy.

A complete diabetes visit note needs to address all of this while remaining readable and clinically useful.

Understanding the Documentation Burden

The average diabetes management visit should address:

• Current glycemic control (recent glucose readings, HbA1c trends)
• Medication adherence and side effects
• Hypoglycemic episodes
• Dietary and exercise habits
• Cardiovascular risk factors (blood pressure, lipids, smoking)
• Microvascular complication screening (eyes, kidneys, feet, nerves)
• Mental health screening (depression, diabetes distress)
• Preventive care (vaccinations, cancer screening)
• Self-management education needs

That's a lot to document clearly and efficiently.

The key is having a systematic approach that ensures nothing gets missed while keeping documentation time reasonable.

Example 1: Type 2 Diabetes, Poorly Controlled on Oral Agents

Patient: 56-year-old female
Chief Complaint: Diabetes follow-up, blood sugars still running high
Visit: Established patient, diabetes management

S – Subjective:

Patient presents for diabetes follow-up. Diagnosed with Type 2 diabetes 3 years ago. Currently on metformin 1000mg BID and glipizide 10mg BID. Home glucose monitoring inconsistent but reports fasting readings typically 180-220 mg/dL, occasional post-meal checks up to 280 mg/dL. Last HbA1c 3 months ago was 8.9%. Denies polyuria, polydipsia, or unintentional weight loss. Reports occasional episodes of feeling shaky and lightheaded mid-afternoon, relieved by eating snack—suspect mild hypoglycemia but not checking glucose during these episodes.

Diet consists of large portions at dinner, skips breakfast most days, frequent snacking on crackers and chips. No regular exercise due to knee pain. Family history significant for father with diabetes and complications (amputation, dialysis). Takes medications most days but sometimes forgets evening dose when eating dinner out. Feels overwhelmed by diabetes management, states "I try but nothing seems to work."

O – Objective:

Vital Signs: BP 142/88, HR 82, Wt 198 lbs (up 4 lbs from 6 months ago), BMI 34.2
General: Obese female, cooperative, appears tired
Eyes: Visual acuity 20/30 both eyes with correction
Cardiovascular: Regular rate and rhythm, no murmurs
Extremities: Trace bilateral lower extremity edema
Diabetic Foot Exam: Monofilament sensation intact bilaterally, pedal pulses palpable, no ulcerations or deformities, mild callus formation on plantar surface bilateral feet, toenails thickened
Labs (drawn today): HbA1c 9.2% (increased from 8.9%), fasting glucose 215 mg/dL, creatinine 1.1 mg/dL, eGFR 62 mL/min, urine albumin/creatinine ratio 42 mg/g (microalbuminuria present), LDL 118 mg/dL, HDL 38 mg/dL, triglycerides 245 mg/dL
Last eye exam: 14 months ago, no retinopathy noted at that time

A – Assessment:

Type 2 diabetes mellitus, poorly controlled with HbA1c 9.2% despite dual oral therapy. Multiple barriers to control identified: inconsistent medication adherence, suboptimal dietary habits, sedentary lifestyle, possible diabetes distress. Current regimen inadequate to achieve glycemic targets.

Complications present: early diabetic kidney disease evidenced by microalbuminuria and reduced eGFR, hypertension, dyslipidemia. Patient at high cardiovascular risk. Not currently at HbA1c goal of less than 7% for patient this age without significant comorbidities. Requires medication intensification and enhanced diabetes self-management support.

P – Plan:

Glycemic Management: Current oral regimen at maximum doses but insufficient. Discussed options for intensification: adding basal insulin vs adding GLP-1 receptor agonist. Patient apprehensive about injections but willing to consider after education. Initiating dulaglutide 0.75mg weekly subcutaneous injection. Provided teaching on injection technique, pen storage, and injection site rotation. Explained potential GI side effects (nausea, decreased appetite) typically improve over 2-4 weeks. Continue metformin 1000mg BID (provides cardiovascular benefit). Discontinuing glipizide to reduce hypoglycemia risk with addition of GLP-1 agonist.

Glucose Monitoring: Emphasized importance of consistent home monitoring. Instructed to check fasting glucose daily and 2-hour post-meal once daily (varying meals). Record readings in log book. Check glucose during any hypoglycemic symptoms. Reviewed hypoglycemia recognition and treatment with 15 grams fast-acting carbohydrates.

Lifestyle Modification: Referred to diabetes educator for comprehensive medical nutrition therapy. Key goals: portion control, regular meal timing including breakfast, reducing processed carbohydrates, increasing vegetables. Discussed starting gentle exercise like walking 10-15 minutes daily despite knee pain. Provided information on diabetes support groups.

Complication Screening: Microalbuminuria detected, initiating lisinopril 10mg daily for renal protection and blood pressure control per guidelines. Scheduled ophthalmology referral for dilated eye exam (overdue). Continue annual diabetic foot exams. Ordered baseline EKG given cardiovascular risk factors.

Cardiovascular Risk Management: Initiating atorvastatin 20mg daily for primary cardiovascular prevention given diabetes plus multiple risk factors. Target LDL less than 100 mg/dL. Low-dose aspirin 81mg daily recommended but patient declined due to GI concerns—will revisit at next visit.

Patient Education: Provided extensive counseling on diabetes complications and importance of glycemic control. Addressed diabetes distress, offered referral to behavioral health which patient will consider. Emphasized this is chronic condition requiring ongoing management, not personal failure. Scheduled 30-minute phone follow-up with nurse in 2 weeks to address medication questions and review glucose logs.

Follow-up: Return in 6 weeks for medication adjustment and symptom check. Repeat HbA1c in 3 months to assess response to new regimen. Annual comprehensive metabolic panel, lipid panel, and urine albumin/creatinine ratio. Patient verbalized understanding of plan and importance of medication adherence and lifestyle changes.

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Example 2: Type 2 Diabetes, Well-Controlled on Metformin Alone

Patient: 48-year-old male
Chief Complaint: Routine diabetes check
Visit: Established patient, annual comprehensive visit

S – Subjective:

Patient returns for annual diabetes visit. Diagnosed with Type 2 diabetes 2 years ago, initially HbA1c 7.8%. Currently managed with metformin 1000mg BID and lifestyle modifications. Reports excellent adherence to low-carbohydrate diet, lost 35 lbs since diagnosis through diet and exercise. Exercises 5 days weekly (jogging 30-40 minutes). Home glucose readings consistently 90-110 mg/dL fasting, 110-130 mg/dL post-meal. Denies polyuria, polydipsia, vision changes, or neuropathic symptoms. No hypoglycemic episodes. Takes metformin with meals without GI side effects. Motivated and engaged in self-management.

O – Objective:

Vital Signs: BP 118/76, HR 64, Wt 182 lbs (down from 217 at diagnosis), BMI 26.7
General: Well-appearing, fit male in no distress
Eyes: Last dilated exam 3 months ago, no retinopathy
Cardiovascular: RRR, no murmurs, no edema
Diabetic Foot Exam: Monofilament 10g sensation intact all sites bilaterally, no skin breakdown, no deformities, pulses strong, skin warm and well-perfused
Labs (fasting, drawn today): HbA1c 6.2%, glucose 98 mg/dL, creatinine 0.9 mg/dL, eGFR greater than 90 mL/min, urine albumin/creatinine ratio less than 10 mg/g (normal), LDL 92 mg/dL on atorvastatin 20mg daily, HDL 52 mg/dL, triglycerides 98 mg/dL
Vaccinations: Influenza current, pneumococcal complete, COVID-19 boosters current

A – Assessment:

Type 2 diabetes mellitus, excellent control with HbA1c 6.2% on metformin monotherapy. Patient demonstrates exemplary self-management with significant sustained weight loss, regular exercise, and dietary modifications. No evidence of diabetes complications: normal kidney function, no albuminuria, no retinopathy on recent screening, no neuropathy. Cardiovascular risk factors well-managed: blood pressure at goal, lipids at goal on statin therapy. Patient represents optimal diabetes management with lifestyle-first approach supported by metformin.

P – Plan:

Continue Current Regimen: Metformin 1000mg BID, atorvastatin 20mg daily. No medication changes needed given excellent control. Patient to continue current diet and exercise routine. Reinforced importance of maintaining these healthy habits long-term.

Monitoring: Continue home glucose monitoring 3-4 times weekly to maintain awareness. Next HbA1c in 6 months. Annual comprehensive metabolic panel and lipid panel.

Preventive Care: Annual diabetic foot exam completed today, normal findings. Eye exam current, next due in 12 months. Discussed colon cancer screening options (patient turning 50 next year), will address at next visit. All vaccinations current.

Recognition and Encouragement: Commended patient on outstanding diabetes management and lifestyle changes. Discussed that sustained weight loss and exercise have likely reduced cardiovascular risk substantially. Encouraged him to maintain current approach rather than become complacent.

Follow-up: Return in 6 months for routine diabetes visit unless concerns arise earlier. Continue annual comprehensive visits. Patient has good understanding of diabetes self-management and when to seek care.

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Example 3: New Diabetes Diagnosis with Patient Education Focus

Patient: 62-year-old female
Chief Complaint: Follow-up on recent diabetes diagnosis
Visit: New diabetes education and treatment initiation

S – Subjective:

Patient returns 1 week after diabetes diagnosis made during annual physical (HbA1c 8.4%, fasting glucose 178 mg/dL). Feeling shocked and anxious about diagnosis, many questions about what this means. Denies current symptoms but in retrospect recognizes increased urination at night past few months. Family history significant for mother and sister with diabetes. Concerned about complications and prognosis. Currently not taking any medications, waiting for this visit to discuss treatment. Diet currently includes regular soda, white bread, pasta, rice with most meals. Works sedentary office job. Previously walked occasionally but not regularly.

O – Objective:

Vital Signs: BP 134/84, HR 78, Wt 175 lbs, BMI 30.8
Labs (from last week): HbA1c 8.4%, fasting glucose 178 mg/dL, random glucose 245 mg/dL, creatinine 0.8 mg/dL, eGFR greater than 90, urine albumin negative
Baseline diabetic foot exam: Monofilament sensation intact, pulses present, no lesions
Baseline dilated eye exam: Scheduled for next month

A – Assessment:

Type 2 diabetes mellitus, newly diagnosed, HbA1c 8.4%. Patient without current symptoms but glucose elevation sufficient to diagnose diabetes. No evidence of complications at baseline. Patient appropriate candidate for metformin initiation combined with intensive lifestyle modification education. Significant patient education needs regarding diabetes pathophysiology, complications, self-management, and treatment rationale.

P – Plan:

Diabetes Education (30 minutes spent on education and counseling):

What is Diabetes: Explained that diabetes is chronic condition where body cannot properly process glucose, leading to elevated blood sugars. Discussed difference between Type 1 and Type 2, emphasizing patient has Type 2 which is most common form. Explained this is not caused by eating too much sugar, but rather complex interplay of genetics, weight, and metabolic factors.

Why Treatment Matters: Reviewed potential complications including heart disease, stroke, kidney disease, vision loss, nerve damage, and foot problems. Emphasized that good glucose control significantly reduces these risks. Discussed treatment goals: target HbA1c less than 7%, fasting glucose 80-130 mg/dL, post-meal glucose less than 180 mg/dL.

Lifestyle Modifications: Provided extensive dietary counseling focusing on carbohydrate awareness and portion control rather than restrictive "diabetic diet." Key messages: limit refined carbohydrates and sugary beverages, choose whole grains, increase vegetables, watch portion sizes. Encouraged 150 minutes weekly physical activity, starting with 20-minute walks after dinner. Discussed weight loss goal of 5-10% body weight can significantly improve glucose control.

Medication Initiation: Starting metformin 500mg once daily with dinner for 1 week, then increase to 500mg twice daily (with breakfast and dinner) if tolerated. Explained metformin helps body use insulin more effectively and lowers glucose production by liver. Reviewed GI side effects (diarrhea, nausea) usually improve within 2-4 weeks. Taking with food reduces side effects. Provided written information on metformin.

Glucose Monitoring: Prescribed blood glucose meter and test strips. Taught proper finger stick technique and meter use. Instructed to check fasting glucose daily and occasionally 2 hours after largest meal. Provided log book for recording values. Reviewed target ranges and when to call with concerning values.

Complication Screening: Scheduled ophthalmology appointment for baseline dilated retinal exam. Completed baseline foot exam today. Annual kidney function testing. Discussed importance of regular dental care and foot care.

Support Resources: Referred to diabetes educator for follow-up teaching session. Provided American Diabetes Association website for reliable information. Gave patient "Living with Diabetes" booklet. Encouraged bringing family member to next visit to involve support system.

Follow-up: Return in 4 weeks to review home glucose logs, assess medication tolerance, and discuss any questions or concerns. Repeat HbA1c in 3 months to assess treatment response. Phone call from nurse in 1 week to check on medication side effects and answer questions. Patient provided with direct phone number for diabetes care team. Emphasized this is beginning of journey and we will work together to manage diabetes effectively. Patient appeared less anxious after education session, verbalized basic understanding of diabetes and treatment plan.

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Essential Elements Every Diabetes SOAP Note Must Include

After reviewing thousands of diabetes documentation audits, here are the non-negotiable elements:

HbA1c Value and Date

Don't write "HbA1c elevated" or "diabetes uncontrolled." Record the actual value and when it was drawn. Quality measures cannot count missing values.

Medication List with Doses

List all diabetes medications with specific doses. This is critical for prior authorization documentation showing stepwise therapy.

Evidence of Self-Management Assessment

Document glucose monitoring frequency, dietary habits, exercise patterns, and medication adherence. This shows comprehensive care beyond just prescribing.

Complication Screening Status

Annual requirements include: diabetic foot exam, dilated eye exam, urine microalbumin, kidney function tests. Document when completed or scheduled.

Cardiovascular Risk Management

Document blood pressure, statin therapy, aspirin use (or contraindications), and smoking status. These are separate quality measures tied to diabetes care.

Target Goals Stated

Document specific HbA1c goal for this individual patient (may vary based on age, comorbidities, hypoglycemia risk).

Patient Education Provided

Quality measures want documentation that you counseled on lifestyle, complications, and self-management—not just prescribed medications.

Hypoglycemia Assessment

Ask about and document any hypoglycemic episodes, especially when on insulin or sulfonylureas.

Common Documentation Pitfalls to Avoid

"Diabetes uncontrolled, increase metformin" → This fails to document current HbA1c value, barriers to control, or rationale for medication choice.

Missing foot exam documentation → Annual diabetic foot exams are quality measures. "Feet examined, normal" isn't sufficient—document monofilament testing, pulses, skin integrity.

No documentation of medication adherence barriers → When diabetes is poorly controlled, you must document whether it's due to non-adherence, medication inadequacy, or lifestyle factors.

Ordering expensive medications without documentation of metformin trial → Prior authorizations require documented stepwise therapy progression.

Not documenting patient's understanding of self-management → Education quality matters. Did the patient demonstrate understanding? Can they state their target glucose range?

Ignoring mental health screening → Depression significantly impacts diabetes management. Document screening, even if negative.

Missing preventive care documentation → Flu shot, pneumonia vaccine, smoking cessation counseling, and age-appropriate cancer screening should be addressed.

Diabetes Documentation Efficiency Strategies

The challenge with diabetes notes is thoroughness without verbosity. Here's how to document efficiently:

Use bullet points for review of systems specific to diabetes complications: "ROS: Denies polyuria, polydipsia, vision changes, foot pain, paresthesias."

Create templates for annual comprehensive exams that include all required preventive care elements as checkboxes.

Document home glucose logs quantitatively: "Average fasting glucose 165 mg/dL, range 142-198 mg/dL" rather than "running high."

State medication changes with explicit rationale: "Adding basal insulin glargine given HbA1c 9.2% despite maximum dose dual oral therapy per ADA treatment algorithm."

Document education topics covered: "Counseled on sick day management, hypoglycemia recognition and treatment, foot care, and importance of medication adherence."

Reference previous values for comparison: "HbA1c 7.8% today, improved from 8.9% three months ago, demonstrating good response to regimen changes."

How SOAP Notes Doctor Streamlines Diabetes Documentation

When you use SOAP Notes Doctor for diabetes visits, the system automatically:

• Structures HbA1c values prominently with trend comparison
• Includes comprehensive complication screening documentation
• Documents medication stepwise progression for prior authorizations
• Incorporates quality measure requirements systematically
• Captures patient education topics in audit-friendly language
• Ensures cardiovascular risk management documentation
• Prompts for preventive care status
• Uses appropriate terminology throughout

You simply record the clinical findings—glucose values, medication changes, exam findings, what you discussed with the patient.

The system organizes everything to satisfy insurance requirements, quality measures, and clinical standards simultaneously.

Try it at soapnotes.doctor and reclaim hours of your week currently spent on diabetes documentation.

Final Thoughts

Diabetes documentation complexity reflects the complexity of diabetes care itself—multiple organ systems, numerous medications, extensive self-management requirements, and ongoing complication prevention.

The documentation burden is real, but it doesn't have to be overwhelming.

Focus on capturing the essential elements: actual values (HbA1c, glucose readings, blood pressure), medication specifics with rationale, complication screening status, and patient education topics.

These elements satisfy quality measures while creating clinically useful notes that support excellent patient care.

Your documentation should reflect the comprehensive care you provide, not create additional barriers to providing it.

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