CP04 Insulin and Blood Glucose - Devon Partnership NHS Trust

Appendix 1
DIABETES CHART
For the Prescribing, Administration and Monitoring of Insulin
Name NHS No Date of Birth
Ward Consultant Sex M / F
PRESCRIBED INSULIN TREATMENT REGIME
Insulin Insulin Dose/Dose Range (units)* Doctor
Full Product Name Device B’fast Lunch Dinner Bed signature
Date
Pharm
signature
A
B
C
*state number only, do not use abbreviations U or IU
PLEASE ENSURE THAT MONITORING REQUIREMENTS ARE COMPLETED OVERLEAF AT TIME OF
PRESCRIBING
Date of
test
RECORD OF BLOOD GLUCOSE (BG) RESULTS
Time
of test
BG
result
Mmol/l
Staff
Initials
Response / Comments
(eg: Hypoglycaemic
Events, UTI, post meal)
RECORD OF INSULIN ADMINISTRATION
Date
of
admin
Time
of
admin
Insulin
A/B/C
Actual
Dose
Units
Nurses
Initials
THIS FORM (ID F11) IS INCLUDED IN THIS CLINICAL PROTOCOL FOR
INFORMATION ONLY
TO OBTAIN A COPY OF THIS FORM PLEASE CONTACT MEDICINES
MANAGEMENT ON 01392 675674 OR EMAIL
Dpn-tr.pharmacyteam@nhs.net
CP04 Prescribing and Administering Insulin and Monitoring Blood Glucose
Approved by Drug and Therapeutics Committee: April 2014
Review Date: April 2016
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