Diabetes Checklist for:
SURNAME
 COMMENCMENT OF INSULIN
 CHANGING INSULIN REGIMEN
MRN
OTHER NAMES
ADDRESS
DATE OF BIRTH
AGE
To be completed by the Medical Officer and Nurse providing the inpatient education
for patients commencing insulin. Tick the boxes when attended.
Insulin regimen: Medical Officer to complete and sign
Insulin Type: ________________________
Device Type: _________________________
Starting Dose:
Needle size:
Medical Officer’s Signature _______________________ Print Name______________________
Designation _____________________________
Date_________________
Referred to (early referral to specialised diabetes team as required):
Endocrinologist  Date _____________
Dietitian  Date ___________
GNC Diabetes Education  Date ___________
Note: Arrange referral marked as “Urgent Insulin Education” to GNC Diabetes Service and fax to
RIMS on 49223895
GP discharge letter provided 
Checklist: Nurse to complete and sign

Integrity and expiry date of insulin checked Yes
No 
Insulin Administration Instruction attended and patient competency
Instructed Competent
Advised


Injection site selection

How to insert pen cartridge if required 

Injection site rotation

How to mix insulin if required


Importance of using needle once 
How to apply pen needle correctly


Insulin storage and shelf life

Correct dialling of dose


How insulin works

Angle of injection


How to obtain supplies

Skin fold, if required


Sharps disposal

Hold needle in situ for 10-12 secs


How to use insulin delivery device
1
Education Checklist for Inpatients Commencing Insulin Therapy
Diabetes Checklist for:
SURNAME
 COMMENCMENT OF INSULIN
 CHANGING INSULIN REGIMEN
MRN
OTHER NAMES
ADDRESS
DATE OF BIRTH
AGE
Hypoglycaemia Instruction included:
Advised
Advised
Causes and prevention

Level at which to treat

How to treat

Hypo kits

Glucagon instruction (if needed)

Medical Alert identification

Blood Glucose Testing:
Instructed Competent
Patient’s technique checked


Advised

Record diary
BGL testing regime

Target range for BGLs: 5-10mmol/L  (this is the ADS inpatient management recommendation)
Other range 
Please specify _______________________________
Meter supplied for those without meter 
New NDSS registration 
NDSS card upgraded for insulin 
or
Diabetes and Driving:
Patient informed about notifying Roads and Maritime Services of insulin therapy & issued with the
NDSS Diabetes & Driving Brochure:
yes 
no 
n/a 
Handouts Issued (Australian Diabetes Council Fact Sheets):
Insulin Administration Instruction Sheet

Other (specify)

Insulin and Diabetes

________________________________
Balancing food, activity & insulin

________________________________
Blood Glucose Monitoring

________________________________
Hypoglycaemia

Diabetes and Driving NDSS brochure

Additional Comments:
______________________________________________________________________________
__________________________________________________________________
Nurse’s Signature _________________________ Print Name________________________
Designation __________________________
Date_________________
2
Education Checklist for Inpatients Commencing Insulin Therapy