UNIVERSITY OF NORTH CAROLINA HOSPITALS
CHAPEL HILL, NORTH CA
Diabetes Hospital Patient Self-Management Order Form
Page 1 of 2– MIM # 1190 INSULIN PUMP
Medicare will only pay for services that it determines to be reasonable and necessary
under section 1862 (a) (1) of the Medicare Law. When ordering tests for which Medicare
reimbursement will be sought, physicians should order only those individual tests that are
necessary for the diagnosis and treatment of a patient, rather than for screening purposes.
NOTE: Another brand of drug identical in form and content may be
dispensed unless otherwise indicated.
1. Self-monitoring of capillary blood glucose:
 Endocrine consult (use of this form requires a mandatory Endocrine consult. Pager: 216-6660)
 Patient to self-monitor blood glucose as prescribed below using own glucose meter. Nursing staff will retain a daily chart
copy of the 24-hour hospital patient log.
 Nursing staff may monitor blood glucose using hospital glucose meter, patient may use the result to adjust insulin dosage
 QAC and QHS
 _____ hrs after each meal
 0300
 Other ______________________________________
 NO CHANGE TO EXISTING ORDERS FOR CAPILLARY BLOOD GLUCOSE MONITORING
2. Basal Rates by continuous subcutaneous infusion of insulin:
Basal rate using insulin (aspart/Novolog)
 Select 00:00 or 12AM (MN) in the “Time” row below
 Indicate the programmed 00:00 or 12 AM basal infusion rate of insulin aspart (Novolog) in “Units/hr”
Basal rate changes: each time the basal rate changes select a “Time” box; enter the start time of that programmed basal rate,
enter the rate in units of aspart (Novolog) per hour.
00: 00 









Time
or 12AM
Units/hr
______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
Entries above are in units of insulin per hour. Rate continues until a new rate starts (see- Time).
24 Hr BASAL Insulin Total________
3. Boluses by continuous subcutaneous infusion of insulin:
Instructions
 Breakfast ~0800  Lunch ~1100
Select mealtimes 
Insulin Prandial doses
(aspart/Novolog):
Select 1 under each
mealtime
__________ units/meal, or
______ units/serving (15g
of carbohydrate), or
1 unit/ __________ g
(grams of carbohydrate)
__________ units/meal, or
_______ units/serving (15g
of carbohydrate), or
1 unit/ __________ g
(grams of carbohydrate)
 Supper ~1700
 Snack ~2200
__________ units/meal, or
_______ units/serving (15g
of carbohydrate), or
1 unit/ __________ g
(grams of carbohydrate)
__________ units/meal, or
_______ units/serving,
(15g of carbohydrate) or
1 unit/ __________ g
(grams of carbohydrate)
 _________ unit(s) for every __________ mg/dL blood glucose (BG) above _________ (target BG)), or
Correction doses of
insulin
(aspart/Novolog):
Select 1
 Pump BG target________ at 12 AM (MN)
Sensitivity*_______ at 12 AM (MN)
 Pump BG target________ at 2nd start time_________ Sensitivity*________ at 2nd start time________
 Pump BG target________ at 3rd start time_________ Sensitivity*________ at 3rd start time________
 Active Insulin Curve [Insulin on Board] _______ hours
Select 1 timing plan for
correction doses
 other: _________________________________________________________________
 before meals
 before and between meals with frequency not to exceed q 2 hour
*Note: insulin sensitivity = expected drop of blood glucose in mg/dl after administration of 1 unit of rapid acting insulin analog (aspart/Novolog).
 “Hold” parameters and comments _________________________________________________________________________
I certify that all tests are medically
necessary:
Provider’s signature/ID#
HD 7035 Lawson # 050299 Revised 2/10
Beeper:
Date/ Time:
White copy-medical record
Transcribed by:
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Chart location-physician’s orders
UNIVERSITY OF NORTH CAROLINA HOSPITALS
CHAPEL HILL, NORTH CA
Diabetes Hospital Patient Self-Management Order Form
(Use Requires Mandatory Diabetes/Endocrine Consult; see Hospital Policy D-15) Pager: 216-6660
Page 2 of 2– MIM # 1190 INSULIN PUMP Patients
Medicare will only pay for services that it determines to be reasonable and necessary
under section 1862 (a) (1) of the Medicare Law. When ordering tests for which Medicare
reimbursement will be sought, physicians should order only those individual tests that are
necessary for the diagnosis and treatment of a patient, rather than for screening purposes.
NOTE: Another brand of drug identifical in form and content may be
dispensed unless otherwise indicated
4. CALL Parameters
 Call HO with blood glucose < 80 mg/dL or > 400 mg/dL , and treat if < 80 mg/dL (see below)
 Call HO with blood glucose < _______ or > _________, and treat if < 80 mg/dL (see below)
Call HO if the following occur:
 No self-monitoring of blood glucose documented on hospital “Patient Log” form for > 8 hrs
 24-hr administration of insulin by pump < 80% of the ordered basal amount during previous 24 hr period ( <
______ units )
 Sounding of insulin pump alarm that patient cannot trouble-shoot, correct, and silence
 Special orders or call parameters: _____________________________________________________________
 No change to existing orders for call parameters
ALGORITHM
ORDER TO TREAT PATIENT BLOOD GLUCOSE < 80 mg / dL
CONSCIOUS PATIENT – ABLE TO EAT
1.
UNCONSCIOUS PATIENT /NPO with IV ACCESS
Provide with 15 g of carbohydrate, e.g.
- glucose tablets,
- 4-6 oz. fruit juice,
- 4-6 oz. regular (non-diet) soda, or
- one cup milk, etc.
2. If patient is UNCONSCIOUS and unresponsive
Call Adult Code Blue (6-4111)
2.
Re-check blood glucose after 10-15 minutes.
4.
3.
Repeat steps 1 & 2 if blood glucose remains less than 80
mg/dL.
Call HO to assess need for supplementary carbohydrate
and/or revision of scheduled insulin or correction dose
therapy
4.
1. Administer 12.5 grams of 50 % dextrose IV.
3. Re-check blood glucose in 5 minutes.
If blood glucose is less than 80 mg/dL at 5 minutes repeat
step 1 and re-check blood glucose in 5 minutes.
UNCONSCIOUS Patient or NPO and no IV access
1.
Administer glucagon 1 mg IM.
2.
If patient is UNCONSCIOUS and unresponsive Call Adult
Code Blue (6-4111)
3.
Recheck blood glucose in 5–10 minutes.
4.
If blood glucose less than 80 mg / dL AND patient still
unconscious,
start an IV line, and give 12.5 gms of 50 % dextrose IV
-
After initiation of treatment for blood glucose < 80 mg / dL, call HO to assess need for supplementary carbohydrate
and/or revision of scheduled insulin or correction dose therapy.
Interventions should be documented in the nursing notes section of E-chart
I certify that all tests are medically necessary:
Provider’s signature/ID#
Beeper:
Date / Time:
Transcribed by:
Checked by:
Reference: Hypoglycemia in the Non-Pregnant Adult Patient Policy: NURS 0451
HD 7035 Lawson # 050299 Revised 2/10
White copy-medical record
Pink copy-pharmacy
Chart location-physician’s orders