Using the Insulin Subcutaneous Order & Blood
Glucose Record – Adult
General information
• Ensure patient identification and facility, ward/unit and year are completed.
• Note any Special Instructions.
Monitoring Record

• Note the BGL frequency in the Monitoring/ Notification Instructions section
If not documented, default monitoring is Standard: Pre meals and at 21:00hrs.
• If required the BGL frequency can be updated in the Date columns of the Monitoring Record.
• Write the date and the patient’s diet at the top of the column in the Monitoring Record.
• Perform the BGL. Document the time and the BGL number in the row that corresponds with the BGL ranges.
• If the BGL is at an ALERT level take appropriate action.

Administering Insulin

• The form is used for BGL monitoring as well as Routine; Supplemental and Stat/ Phone Insulin Orders
• All insulin orders should be cross referenced on the National Inpatient Medication Chart ( NIMC)
• The prescriber should write the insulin’s full trade name in the Administration Record, however if the row is blank and the patient
requires administration of insulin, the nurse or pharmacist can write the Name of Routine or Supplemental Insulin.
• Administration of insulin doses is documented in the Administration Record. Document the dose administered against the
corresponding Name of routine insulin or Name of supplemental insulin in the Administration Record.
• Document the time insulin is given and initial to acknowledge administration
Routine insulin Orders
•
•
•
•
•

Routine doses of insulin are ordered in the in the Routine Insulin Orders section. Doses must be ordered for each day.
If no dose is ordered where one would be expected, contact the prescriber to determine if a dose is required and provide order.
Calculate, prepare and administer the dose/s (some patients may require more than one type of insulin at one time).
Document the dose administration in the Administration Record.
If clinical judgement indicates a prescribed dose should not be administered (e.g. patient is vomiting). Enter code W for withheld
and notify the doctor to review patient.
Supplemental Insulin Orders
• Some patients may be ordered supplemental insulin to assist control of erratic BGLs. This will usually be in addition to a routine
insulin dose.
• Determine if supplemental insulin is required for that Meal / time according to the BGL ranges for which it is prescribed.
• Calculate, prepare and administer the dose.
• Document the administration in the Administration Record .
• Supplemental insulin and routine insulin of the same type may be administered together but must be documented separately.

Stat / Phone Insulin Orders
• If a phone order is taken for any insulin dose document the order in the Stat/ Phone Insulin Orders. Check if the Stat / Phone order
replaces or is in addition to other insulin orders.
• A second nurse must read back the order to the doctor to confirm it is correct and then countersign.
• Document the administration of phone order insulin in the Administration Record and cross reference the order by writing ‘phone’
in the dose box in the Routine Insulin Orders.

Diabetes treatment prior to admission
• Write this information in the space provided. Include oral hypoglycaemic agents and/or insulin names and doses. Include optional
information such as insulin device used.
Pharmacy Review

• The clinician undertaking the pharmacy review will sign this section as a record that they have reviewed the insulin form (on the
corresponding day) to ensure that all insulin orders are clear, safe and appropriate for that individual patient.