Quality Standards for Diabetes Care Toolkit

Care planning and goal/target setting

The National Institute for Health and Care Excellence guidelines (2010) recommend the following.

An individual care plan should be set up and reviewed annually, modified according to changes in wishes, circumstances and medical findings, and the details recorded. The plan should include aspects of:

diabetes education including nutritional advice (see Standard 1)

insulin therapy (see Standard 7)

self-monitoring (see Standard 5)

arterial risk factor surveillance and management (see Standards 5 and 6)

late complications’ surveillance and management (see Standards 9–12).
It is also recommended that population, practice-based and clinic diabetes registers be used to assist programmed recall for annual review and assessment of complications and vascular risk (NICE 2010).