UNIVERSITY OF NORTH CAROLINA HOSPITALS
CHAPEL HILL, NORTH CAROLINA 27514
Diabetes Hospital Patient Self-Management Daily Flow Sheet
“Patient Log” for INSULIN PUMP
Page 1 of 1– MIM #1189
Date: _______________________________
Diabetes self-management orders reviewed daily with
patient & when changes to orders are made.
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
5.
6.
7.
8.
9.
want to see it also.
Forms will be picked up every morning.
Keep your copy, and give your nurse the chart
copy.
If you need insulin, syringes, alcohol wipes or
lancets, tell your nurse*.
If you cannot self-manage, tell your nurse.
If you are not able to self-manage, nursing will
take over your diabetes care & your medical
team will be notified.
NOTE: No insulin pump supplies except insulin are provided.
 Using hospital glucose meter
 Using own glucose meter
Registered Nurse to record on first
log, then verify daily:
Brand name of patient glucose meter
_______________________________
Strip Lot # ______________________
Expiration date __________________
Strip/Chip Code # __________________
(If applicable)
Call the nurse
if your blood glucose
is less than: ______
or more than: ______mg/dL
Date: ___________ Time: ________
_______________________________
RN Signature
*Regulatory requirements do not allow insulin or syringes at the
bedside.
Basal rate by pump
• Enter times when basal rate changes (upper row) starting at 12 midnight (12 MN).
• Enter basal rate in units of insulin aspart (Novolog) / hour (lower row).
00:00
Time 12 MN
Units/
hour
Mealtime and correction dose insulin
• Complete left-hand column by checking off method of carbohydrate counting and insulin type.
• Use blank columns to enter time, blood glucose results, carbohydrates counted as grams or servings, and insulin
dose in units.
Time
Blood Glucose
Carbohydrates counted by
 grams  servings
 Units of insulin aspart
(Novolog®)
 Units of regular insulin
Daily Total Insulin by Pump
Total the number of units before turning in form every morning
24-hour daily total insulin shown on pump screen from 12AM (00:00 or midnight) yesterday
to 12AM today
HD 7034 Lawson # 050298 12/09
White copy-medical record
Pink copy-patient
Total _________
Chart location-MAR