UNIVERSITY OF NORTH CAROLINA HOSPITALS
CHAPEL HILL, NORTH CAROLINA 27514
Diabetes Hospital Patient Self-Management Daily Flow Sheet
“Patient Log” for MULTIPLE DAILY INSULIN INJECTIONS
Page 1 of 1– MIM # 871 (revised 2/10)
DATE: ___________________________
Diabetes self-management orders reviewed daily with patient &
when changes to orders are made.
 Using hospital glucose meter
 Using own glucose meter
Patient Instructions:
1. Complete this form daily.
2. Forms are from 12 midnight to 12 midnight.
3. Keep your entries to the form up-to-date.
4. Show your nurse your form; other staff may want to see
it also.
5. Forms will be picked up every morning.
6. Keep your copy, and give your nurse the chart copy.
7. If you need insulin, syringes, alcohol wipes or lancets,
tell your nurse*.
8. If you cannot self-manage, tell your nurse.
9. If you are not able to self-manage, nursing will take over
your diabetes care & your medical team will be notified.
*Regulatory requirements do not allow insulin or syringes at the bedside.
Registered Nurse to record on first log,
then verify daily:
Brand of patient glucose meter:
________________________________
Strip Lot #:____________________
Strips Expiration date:______________
Strip/Chip Code #:__________________
(If applicable)
Call your nurse
if your blood glucose is less than: ______
or greater than: ______mg/dL
Date & Time:
RN Signature:
Intermediate-acting, long-acting, peakless or premixed insulin by subcutaneous injection
[Examples: Insulin glargine (Lantus®), NPH, Insulin 70/30 (NPH/Regular)]
Time:
Time:
Time:
Type of insulin:
Type of insulin:
Type of insulin:
Dose (units):
Dose (units):
Dose (units):
Mealtime and correction dose insulin
Enter time, blood glucose results, carbohydrates counted as grams or servings, and insulin dose in units.
Time_____ Time______ Time______ Time______ Time______ Time______ Time______ Time______ Time______
Blood Glucose
Check method
used to count
carbohydrates
Check type of
insulin
Units of Insulin
 grams
 servings
 grams
 servings
 grams
 servings
 grams
 servings
 grams
 servings
 aspart aspart aspart aspart aspart aspart
 aspartNovolog Novolog Novolog Novolog Novolog Novolog Novolog
 aspartNovolog
 aspartNovolog
 Regular
 Regular
 Regular
 Regular
 grams
 grams
 servings  servings
 Regular
 Regular
 grams
 servings
 Regular
 grams
 servings
 Regular
 Regular
_____units _____units _____units _____units _____units _____units _____units _____units _____units
Daily Total Insulin (Total the number of units before turning in form every morning)
__________ units
Enter 24-hour daily total insulin injected. Add units of all insulin types injected.
HD 7034 Lawson # 050298 2/10
White copy-medical record
Pink copy-patient
Chart location-MAR