Diabetes Medical Management Plan (Dmmp) Template Page 4
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7Insulin therapy
(continued)
Adjustable (Basal-bolus) Insulin Therapy
•
Carbohydrate Coverage/Correction Dose: Name of insulin: ____________________________________________
•
Carbohydrate Coverage:
Lunch: 1 unit of insulin per ______ grams of carbohydrate
Insulin-to-carbohydrate ratio:
Snack: 1 unit of insulin per ______ grams of carbohydrate
Breakfast: 1 unit of insulin per ______ grams of carbohydrate
Carbohydrate Dose Calculation Example
Total Grams of Carbohydrate to Be Eaten
= ____ Units of Insulin
Insulin-to-Carbohydrate Ratio
Correction dose: Blood glucose correction factor (insulin sensitivity factor) = ______ Target blood glucose = ______ mg/dL
Correction Dose Calculation Example
Current Blood Glucose – Target Blood Glucose
= ____ Units of Insulin
Correction Factor
Correction dose scale (use instead of calculation above to determine insulin correction dose):
Blood glucose ______ to ______ mg/dL, give ______ units
Blood glucose ______ to ______ mg/dL, give ______ units
Blood glucose ______ to ______ mg/dL, give ______ units
Blood glucose ______ to ______ mg/dL, give ______ units
See the worksheet examples in Advanced Insulin Management: Using Insulin-to-Carb Ratios and Correction Factors
for instructions on how to compute the insulin dose using a student’s insulin-to-carb ratio and insulin correction factor.
When to give insulin:
Breakfast
Carbohydrate coverage only
Carbohydrate coverage plus correction dose when blood glucose is greater than ______ mg/dL and ____ hours since last
insulin dose.
Other: __________
Lunch
Carbohydrate coverage only
Carbohydrate coverage plus correction dose when blood glucose is greater than ______ mg/dL and ____ hours since last
insulin dose.
Other: __________
Snack
No coverage for snack
Carbohydrate coverage only
Carbohydrate coverage plus correction dose when blood glucose is greater than ______ mg/dL and ____ hours since last
insulin dose.
Correction dose only: For blood glucose greater than ______ mg/dL AND at least ____ hours since last insulin dose.
Other: __________
Page 4 of 7, DMMP
Tools for Effective Diabetes Management
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