Insulin Subcutaneous Order And Blood Glucose Record

Insulin subcutaneous Order and

Facility:

(Affix identification label here)

..............................................................................................................

Blood Glucose Record - Adult

Ward / Unit:

Year: 20

UrN:

..................................................................................................

....................................

NOT A VALiD

Monitoring Record

Family name:

PreSCriPTiON UNLeSS

Date

Given name(s):

iDeNTiFierS PreSeNT

Change BGL to

Standard

2hrs post-meal

Standard

2hrs post-meal

Standard

2hrs post-meal

Standard

2hrs post-meal

Standard

2hrs post-meal

Address:

(tick all that apply)

At 02:00am

Other:

At 02:00am

Other:

At 02:00am

Other:

At 02:00am

Other:

At 02:00am

Other:

........................

Date of birth:

Sex:

Diet

First Prescriber to Print Patient Name and Check Label Correct:

Time

BGL

(mmol/L) Write in

.......................................................................................................................................................................................................

corresponding range box

mmol/L

ALeRts

Monitoring / Notification Instructions

Greater

Notify doctor

than 20

immediately

than 20

BGL Frequency (tick all that apply)

Notify if 2 consecutive

16.1–20

Standard (Pre-meals and at 21:00hrs)

BGLs greater than 16

At 02:00am

Notify if 3 consecutive

12.1–16

2 hours post-meal

BGLs greater than 12

Other:

8.1–12

if not instructed, default is “Standard”

Medical Officer

4–8

or Ward doctor

to notify:

Treat hypoglycaemia and

Less

Special Instructions:

notify doctor immediately

than 4

Refer to Hypoglycaemia

Ketones

Management (page 4)

Hypo intervention

Doctor notified

Administration Record

Nurses must write the dose given, time

Name of routine insulin:

given and initials

units

If for any reason insulin cannot be

Name of routine insulin:

administered as ordered, notify

units

doctor, enter code

for withheld and

Name of routine insulin:

document in clinical record

units

Name of supplemental insulin:

units

If supplemental short-acting insulin is

Time given

ordered for the same time as routine

short-acting insulin, they may be given

Nurse 1 / 2 initials

together but must be recorded separately

Comments

Routine Insulin Orders

Supplemental Insulin Orders

Stat / Phone Insulin Orders

must be ordered for each day

valid until changed or ceased

also complete Administration Record above

Sliding scale insulin alone is Not recommended, consider basal insulin needs.

Contact doctor if expected dose not ordered.

Check with doctor if order replaces, or is in addition to, other insulin orders.

Date:

mealtime insulin is given at start of meal.

Remember: Adjust routine insulin based on supplemental insulin requirements.

Phone

Prescriber

Date

Date / time

meal / time:

Name of insulin:

Name of insulin

Units

Order

If unsure, seek advice.

prescribed

of dose

Signature

Print your name

Nurse 1 / 2

units

Frequency:

Name of insulin

: Usually the same

Prescriber

Print your

Signature:

name:

as the routine short acting insulin

units

initials

meal / time:

Name of insulin:

With meals only

Breakfast

units

6 hourly

Prescriber

Print your

units

Other (specify):

Signature:

name:

initials

...........................................................................

meal / time:

Name of insulin:

units

it is Not necessary to prescribe supplemental insulin for all patients.

Lunch

units

Prescriber

Print your

units

Start date:

Signature:

name:

initials

If the BGL (mmol/L) is:

meal / time:

Name of insulin:

Start time:

units

Dinner

units

Prescriber

Print your

8.1 – 12

units

.....................................

units

Signature:

name:

initials

Diabetes treatment prior to admission

meal / time:

Name of insulin:

12.1 – 16

then

.....................................

Pre-Bed

units

administer

units

Prescriber

Print your

16.1 – 20

additional:

.....................................

units

Signature:

name:

initials

Greater than 20

meal / time:

Name of insulin:

Pharmacy Review

(and notify Dr)

......................................

Date:

units

Prescriber Signature:

Print your name:

Prescriber

Print your

Signature:

name:

initials

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Insulin Subcutaneous Order And Blood Glucose Record - Adult

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