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3.2 Cross-referencing the national standard medicationchart (NSMC)Before using the chart, it is important for the first prescriber to cross-reference it on theNSMC. This is done by ticking the ‘BGL/Insulin’ box on page 1 of the NSMC. Figure 4 showsan example of how to cross-reference the insulin chart on the NSMC.Figure 4: Additional medication charts section of the National Standard Medication ChartsThis action should also be recorded on the subcutaneous insulin chart, by ticking thecheckbox labelled ‘NIMC (or NSMC) has been marked’. Figure 5 shows that the NSMC hasbeen cross-referenced on the subcutaneous insulin chart.Figure 5: Patient identification section marked to indicate that the NIMC has been cross-referencedIf insulin is to be ordered for the patient, the prescriber should also cross-reference theinsulin order in the regular medications section of the NSMC. (Alternatively, a pharmacist orregistered nurse may do the cross-referencing.) This will help to ensure insulin is not omittedduring the patient’s hospital admission or from their discharge medications. This crossreferencing should be done by one of two methods:1. Attach a pre-printed sticker stating that ‘Insulin is ordered for this patient – seeInsulin/BGL form’ as shown in Figure 6Figure 6: National subcutaneous insulin chart cross-referenced on the NSMCUser guide subcutaneous insulin chart for acute hospitals9

2. Hand-write this information, as shown in Figure 7Figure 7: Alternative method to cross reference the subcutaneous insulin chart on the NIMC3.3 Hospital detailsPrescribers should record the facility name, ward or unit, and year in this section (at the topright-hand side of page 3). Figure 8 shows how this information can be handwritten on thesubcutaneous insulin chart. It is permissible to have some of this information pre-printed onthe chart.Figure 8: Hospital details section3.4 Doctor to notifyThe prescriber should document who is to be notified if any alerts are triggered on the chart,or if any other concerns arise regarding the patient’s diabetes management. If the ‘Doctor toNotify’ box (on the left side of page 2) is left blank, the resident medical officer for thetreating team must usually be notified. The doctor on call should be notified after hours. Anexample of this section can be seen in Figure 9.Figure 9: Doctor to notify in case of emergency or clinical change3.5 Special instructionsClinicians may document any additional information related to the patient’s diabetesmanagement in the ‘Special Instructions’ box (on the left side of page 2) as shown in Figure10.Figure 10: Special instructions panelUser guide subcutaneous insulin chart for acute hospitals10

3.6 Diabetes treatment prior to admissionClinicians should document the patient’s previous treatment in the ‘Diabetes Treatment Priorto Admission section of the chart’ (in the bottom right-hand corner of page 3).This may include oral hypoglycaemic agents and/or insulin names and doses. Optionaladditional information may include the insulin device that the patient uses – for example, thetype of insulin pen.Subsequent prescribers should refer to this information when reviewing the patient’sresponse to treatment. A completed example is shown in Figure 11.Figure 11: Diabetes treatment prior to admission sectionUser guide subcutaneous insulin chart for acute hospitals11

Instructions for monitoring blood glucoselevelsThis section describes how blood glucose levels should be ordered, recorded and monitoredby clinicians.4.1 BGL frequencyBefore the BGL frequency can be specified for a particular day, the date should bedocumented at the top of the relevant ‘Date’ column in the ‘Monitoring Record’ section of thechart. This should be done by the first clinician to write in the ‘Monitoring Record’ column forthat day, whether they are a prescriber or a nurse.Beneath the date, the prescriber can specify the BGL frequency required for that day.Otherwise, the default option is for BGL to be recorded before each meal and at 21:00hours, as indicated by the checkboxes that are pre-ticked on the chart. Prescribers canselect other options by ticking the relevant checkbox. Note that more than one checkbox canbe ticked, and unwanted options that have been ticked can be cancelled by crossing themout. Figure 12 shows an example of how to complete this section.Figure 12: Blood glucose monitoring frequency sectionWhen making these choices, it is important for prescribers to consider whether the patientmight require more frequent BGL monitoring than the default options. For example, anadditional reading at 02:00 hours could be considered if there is a risk of nocturnalhypoglycaemia or the patient is fasting, or an additional reading two hours after meals mightbe useful if the patient is pregnant.User guide subcutaneous insulin chart for acute hospitals12

4.2 Adjusting the chart to accommodate more than sixBGLs for a single dayThe chart has space for up to six BGLs to be recorded each day for up to five days. If morethan six BGLs are required for a single day, the prescriber should also make the followingchanges to the chart to facilitate this: When 7 to 12 BGLs are required, the prescriber should draw a large ‘X’ through thefollowing day’s ‘BGL frequency’ and ‘Diet’ areas, and draw an arrow extending fromthe current date into the middle of the next day’s date label area as shown in Figure13. The same procedure should also be used to modify the Routine Insulin OrderssectionFigure 13: Diagram showing how to order 7-12 blood glucose levels per day If 13 to 18 BGLs are ordered, these ‘X’s’ should be placed in the next two datecolumns and the arrows extended further as seen in Figure 14.Figure 14: Diagram showing how to order 13 to 18 blood glucose levels per dayIf these changes are not made by the prescriber, or if the patient’s monitoring requirementschange at a later time, nurses may also make these alterations to the chart.User guide subcutaneous insulin chart for acute hospitals13

4.3 What to do if BGL readings fall out of alignment withroutine insulin ordersIn some hospitals, patients have their weekend insulin orders written up in advance. In thesefacilities, there is a risk that the BGLs recorded on the chart will fall out of alignment with theroutine insulin orders below. This could happen if there is an unplanned increase in thefrequency of BGL monitoring – for example, because of a hypoglycaemic event.In such cases, nurses should still document all the BGL readings on the subcutaneousinsulin chart, even if they spill over into columns provided for the following day(s), whereroutine orders have already been prescribed. When this happens, the nurse should cross outall the routine insulin doses that have not yet been administered, and contact the prescriberto review the orders. Figure 15 shows a detailed example of this scenario.If the prescriber cannot attend the patient, a phone order should be taken and recorded inthe ‘Stat/Phone Orders’ section and cross-referenced in the ‘Routine Insulin Orders’ section.Figure 15: Diagram showing how to record additional telephone orders and how to record more blood glucoselevels than orderedUser guide subcutaneous insulin chart for acute hospitals14

4.4 DietUnderneath the ‘BGL frequency’ row is a separate ‘Diet’ row for documenting the diet thatthe patient is to receive for the day. This includes checkboxes for full diet, nil by mouth, totalparenteral nutrition (TPN) and clear fluids. Either the prescriber or a nurse can record thesedetails. It should be completed as shown in Figure 16.As well as acting as a record, this information provides a prompt for reassessment of insulinneeds should the patient be fasting for a procedure or have altered dietary requirements.Figure 16: Daily diet sectionUser guide subcutaneous insulin chart for acute hospitals15

Monitoring blood glucose levels andresponding to alertsThis section describes how to monitor blood glucose levels (BGLs) and how to respondappropriately when BGLs do not fall in the accepted range.5.1 Recording BGLsBGLs are recorded in the Monitoring Record section of the chart.To record a BGL: Document the date at the top of the current ‘Date’ column (if blank) Document the diet that the patient is to receive for the day in the ‘Diet’ row (if blank) Document the time when the BGL is measured in the next available time cell for thecurrent day; if it is the first BGL of the day, make sure that it is recorded under thecorrect date – that is, skip over any blank time columns left over from the previous day Measure the patient’s BGL according to local procedure and complete the record asshown in Figure 17 Enter the BGL into the chart, taking care to record the BGL in the row that correspondsto its value (there are six rows in which to record BGLs, with ranges written on the leftand right); act immediately on any instructions in the ALERTS section that align withthat row (see section 5.2).Figure 17: Diagram showing how blood glucose levels should be recorded on the monitoring recordTwo of the rows for recording BGLs do not have any coloured shading. Unless modified (seesection 5.3), these rows correspond to the 4 to 8 and 8.1 to 12 mmol/L ranges. If the BGLfalls within these ranges, a doctor does not need to be notified unless it has been requestedin the Special Instructions, or if the nurse has specific concerns. This is because the targetrange for most inpatients on general wards who are receiving subcutaneous insulin and/ororal treatments is 4 to 10 mmol/L, with up to 12 mmol/L usually regarded as acceptable.User guide subcutaneous insulin chart for acute hospitals16

5.2 AlertsThe chart has a number of alerts embedded within it. If a BGL is recorded within a shadedrow, consult the instructions in the ALERTS section that align with that row, and act on themimmediately. This section outlines the standard actions and notifications required for eachshaded row.The purple row (hypoglycaemia)If the patient’s BGL is less than 4 mmol/L, it will fall within the purple range row, whichindicates hypoglycaemia and a potential emergency. If this occurs, several actions arerequired of the nurse: Initiate hypoglycaemia treatment as per the Guidelines for Treating Hypoglycaemiaflow diagram (on page 4 of the chart), ensuring that the patient’s safety is maintainedat all times; if the patient is unconscious or not cooperative, it is an emergencysituation Notify the treating prescriber or doctor on call at the point specified in the flow diagram,and then place a tick in the ‘Doctor notified’ row in the Monitoring Record After following the flow diagram all the way to the end, place a tick in the‘Hypoglycaemia intervention’ row in the Monitoring Record section Perform follow-up BGLs as specified in the treatment flow diagram and respondaccordingly (see section 11.1) Document the hypoglycaemia treatment and response in the medical record, and inthe ‘Comments’ section of the Administration Record as required.The other coloured rows (hyperglycaemia)The other coloured ranges indicate elevated BGLs, and each level of elevation requires adifferent response.The red rowIf the patient’s BGL is greater than 20 mmol/L, it will fall within the red range row. In thiscase, the nurse should: Perform a urine or blood ketone test (according to local procedure), and document theresult in the ‘Ketones’ row- If a urine ketone test is performed, the result is documented as ‘neg’ if no ketonesare present or as a ‘ ’ or ‘ ’ etc., as indicated on the urine ketone test strip bottle- If a blood ketone test is performed, the result is documented as a number – forexample, ‘0.6’ or ‘1.4’ Notify the treating prescriber or doctor on call immediately, regardless of the ketoneresult, and then place a tick in the ‘Doctor notified’ row in the Monitoring Record Document the actions taken and further relevant information in the ‘Comments’ sectionof the Administration Record, and in the medical record.The orange rowIf the patient’s BGL falls within the orange range row (usually 16.1 to 20 mmol/L unlessmodified), the nurse should: Perform a ketone test, and document the result in the ‘Ketones’ row (as above) If the ketone result is positive, notify the treating prescriber or doctor on callimmediately, and then place a tick in the ‘Doctor notified’ row in the Monitoring Record Document the actions taken and further relevant information in the ‘Comments’ sectionof the Administration Record, and in the medical record.User guide subcutaneous insulin chart for acute hospitals17

The yellow rowIf the patient’s BGL falls within the yellow range row (usually 12.1 to 16 mmol/L unlessmodified) the required response varies.A single elevated BGL that falls in the yellow range row does not require any special action.However, action is required if the patient has had three or more consecutive BGLs greaterthan 12 mmol/L, which may have fallen in any combination of the yellow, orange and redrows. In such cases, the nurse should: Notify the treating prescriber or doctor on call immediately, and then place a tick in the‘Doctor notified’ row in the Monitoring Record Document the actions taken and further relevant information in the ‘Comments’ sectionof the Administration Record, and in the medical record.5.3 Modified BGL rangesSome conditions – for example, pregnancy – may require tighter control of BGL. For thesepatients, a senior doctor may choose to modify some of the ranges printed on the chart.They can do this by crossing out the relevant numbers on both the left and right, andreplacing them with handwritten ranges. Such modifications effectively change thethresholds for both alerts (see section 5.2) and doses of supplemental insulin (see section6.2). A worked example of this scenario is shown in Figure 18.If handwritten modifications result in any ambiguity, the nurse must contact the doctor tocorrect the chart. This includes situations where: The handwritten range only appears on one side of the chartThere is a mismatch between the handwritten ranges on the left and rightTwo ranges overlapThere is a gap between two rangesBGLs had already been recorded on the chart prior to modification.Note that these modifications should always be made before any BGLs have been recordedon the chart. If the chart has already been used, a new chart must be started instead.Such modifications should not be common because only highly experienced insulinprescribers can make them safely.Figure 18: Diagram showing how to modify blood glucose ranges if necessaryUser guide subcutaneous insulin chart for acute hospitals18

Ordering insulinInsulin orders are divided into three sections on the chart: Routine Insulin Orders,Supplemental Insulin Orders and Stat/Phone Orders. The location of each section has beencarefully chosen to reduce the risk of administration errors. Patients may require anycombination of routine, supplemental and stat/phone orders.If no insulin is prescribed for a patient with diabetes, the chart should still be used for BGLmonitoring as the alerts and notification prompts will still apply.Each hospital will have its own specific chart for intravenous insulin, and the subcutaneousinsulin chart should never be used for insulin infusions or pumps.6.1 Routine insulin ordersThe Routine Insulin Orders section (at the bottom of pages 2 and 3) has been designed toalign with the date columns used in the Monitoring Record and Administration Record.Figure 19: Diagram showing a completed regular insulin orders sectionFor each day, there are six rows in which routine insulin doses can be prescribed. Eachdose is prescribed in a different row according to the time when it is to be administered.Figure 19 shows an example of a completed routine insulin orders section.Note that routine insulin orders are not recurrent, so routine insulin must be orderedseparately for each day. When writing up doses, it is appropriate to prescribe for up to fourmeals in advance – for example, for the rest of the present day plus the first dose(s) for thefollowing day. In some circumstances, it may also be appropriate to write up insulin doses forseveral days, but only if the patient’s BGLs have been acceptable and stable in the range of4 to 12 mmol/L.Standard administration times are pre-printed in four of the six rows, namely: Breakfast Lunch Dinner Pre-bed.When these standard administration times are used, all mealtime insulin doses are to begiven immediately before the patient eats, when their meal is in front of them. This includesinsulins with a 15–30 minute delay in onset of action.Rationale: In the hospital setting, meal delivery times are variable and if a meal is delayedafter insulin has been administered, hypoglycaemia may result.User guide subcutaneous insulin chart for acute hospitals19

Prescribers have the option of crossing out a standard administration time label and writing aspecific 24-hour time in the adjacent space instead – see Figure 20.Figure 20: Diagram showing how to amend standard meal times if requiredThere are also two rows – at the top and bottom – that are not pre-labelled with standardadministration times. These can be used when a patient requires two insulin types at asingle meal or time – for example, if a patient receives both their basal insulin and mealtimeinsulin at breakfast.Ordering routine insulinTo order routine insulin, the prescriber must: Consider whether any modifications to the patient’s BGL frequency are required, if notdone already (see section 4.1), noting that the desired BGL frequency for each daymust be specified if frequency deviates from the pre-ticked default options; if morethan six BGLs are requested per day, it is important to adjust the chart accordinglybefore prescribing for the following day to ensure that the order is recorded in thecorrect column (see section 4.2) Write the date that the dose is to be administered at the top of the relevant column inthe Routine Insulin Orders section; if the chart is already in use, take care to ensurethat any dates in the Routine Insulin Orders section match those in the correspondingcolumns of the Monitoring Record Find the appropriate row for the order – for example, the second row if ordering abreakfast dose – and write the full trade/brand name of the insulin to be administeredin the ‘Name of insulin’ column- For a premixed insulin, specify the insulin type in full – for example, ‘Mixtard 30/70’,‘Humalog Mix 25’ and ‘NovoMix 30’- The use of truncations – for example, ‘Mixtard’ and ‘Humalog Mix’ – means that theorder is incomplete and the nurse is not allowed to administer it.- Rationale: Trade names are preferred for insulin prescribing to avoid confusion, asthere are many look-alike or sound-alike generic insulin names which are no

6.4 Administration record 29 Administering insulin and documenting administration 30 7.1 Administration of a routine insulin dose 31 7.2 Administration of a supplemental insulin dose 32 7.3 Administration of a phone order 33 7.4 Examples 34 7.4.1 Routine insulin example 34 7.4.2 Supplemental insulin example 35 7.4.3 Phone order example 36