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National Subcutaneous Insulin Form Pilot
<<< Insert name of Project Officer/Team >>>
<<< Insert name of Hospital >>>
A national pilot project supported by the
Australian Commission on Safety and Quality in Health Care
• Insulin recognised internationally as a high risk
• Standardised Insulin prescribing and
administration forms for adults have been
implemented in Queensland Health hospitals
since 2008
• Need has been established for a nationally
standardised form to accompany the National
Inpatient Medication Chart (NIMC)
Communication and Safety
Insulin Administration
Insulin Orders
Before you start
Cross reference the insulin form on the NIMC
Also cross reference in regular medication order
to ensure that:
– staff refer to the Insulin Subcutaneous Order
– insulin is not omitted from discharge medications.
A sticker is available
Patient Identification
• Affix the current patient identification label (with the
consumer’s name printed underneath)
• As a minimum, the consumer’s name, UR number,
address, date of birth and gender written in legible
Hospital Demographics
• Complete Facility, Year and Ward / Unit
Monitoring / Notification
• Prescriber indicates the
BGL Frequency of
monitoring required
• Default BGL monitoring for inpatients is
Pre-meals and at 21:00hrs
• Consider more frequent BGL monitoring if
Medical Officer to notify / Special
The prescriber should document:
– who to notify of out of range BGLs or other
diabetes related concerns
– any Special Instructions
If no contact name is written, the treating
prescriber or team will be notified
– After hours the doctor on-call will be notified
Diabetes treatment prior to
• The prescriber, pharmacist or nurse writes
the Diabetes treatment prior to admission
in the space provided
– may include oral diabetes medicines and/or
insulin types and doses
– optional additional information may include
the insulin device that the patient was using
Blood Glucose Level (BGL)
Monitoring Section
• Write the Date at the top of the day’s column
• Write the patient’s Diet
– This prompts for re-assessment of insulin requirements
should the patient be fasting for a procedure or be on a
diet such as clear fluids
BGL Monitoring Section
• Write the Time the BGL is measured
• Perform a BGL according to facility procedure
• Write the BGL in the coloured corresponding
with the relevant BGL range
• Note and act on any ALERT instructions in the
BGL ranges
If the BGL is less than 4 mmol/L
Initiate hypoglycaemia management
(see page 4 of chart)
Notify the treating doctor or doctor oncall
Tick the Hypo Intervention and
Dr Notified boxes
Perform follow up BGLs and respond
Document treatment and response on
form and in medical record
High ALERT ranges are:
• BGL greater than 20 mmol/L
• second consecutive BGL greater
than 16 mmol/L
• third consecutive BGL greater than
12 mmol/L
If BGL is in one of the ALERT
• Notify the treating prescriber or
doctor on-call
– Perform a ketone test (urine or blood),
document result in the Ketones box
– Document the actions taken in the
medical record
• Tick the Dr Notified box
Insulin Orders (Prescribing)
• A patient may be prescribed any combination of
Routine, Supplemental, and Stat / Phone Insulin
• If a patient with diabetes is not receiving
subcutaneous insulin, this form should still be
used for BGL monitoring
Routine Insulin Orders (1)
• Six (6) spaces to prescribe routine insulin
– Four (4) spaces with Meal / time pre-printed
• Breakfast
–Two (2)
• Lunch
• Dinner
spaces without
• Pre-Bed
Meal / time
• Use additional sections when a patient requires
2 insulin types at a single meal / time
Routine Insulin Orders (2)
The prescriber must:
• Write the type of insulin (full trade name)
• Sign each order
• Print their name in full at least once
on the form
• Write the date
• Write the dose as a whole number
– Units is pre printed as a watermark
• Initials each dose ordered
– initials is pre printed as watermark
• Insulin doses must be ordered for each day
• It is usually appropriate to also order doses
for the following morning
Routine Insulin Orders (3)
• The prescriber should also write the full
trade name of insulin type/s in the
Administration Record
Routine Insulin Orders (4)
If routine insulin is ceased, the prescriber must:
• Draw a line through the order
• Write the reason for ceasing
the order, the date the order
was ceased and initials
• When the insulin regimen is
being changed, write the
new order on a new
Changing to
mixed insulin
prior to
See new
Supplemental Insulin Orders (1)
• It is not necessary to prescribe
supplemental insulin for all patients
• It might be considered for erratic
BGLs where strict control is required
• Patients may require supplemental
insulin if:
– their condition, dietary intake or
concurrent medications are altering insulin
– optimal doses not yet determined
• May be in addition to a routine
mealtime or basal insulin dose
Supplemental Insulin Orders (2)
• Tick the appropriate Frequency
• Write the Name of insulin, start date and start time
• Standardised BGL ranges are pre printed
– if required, different BGL ranges may be used
• Write insulin doses
– suggested doses available in Table 1 (page 1)
• Supplemental order remains valid until
changed or ceased
• Sign and initial the order
• Review supplemental doses as required
• Changes are validated by initialling
changes in the corresponding column
• Also write the Name of supplemental
insulin in the Administration Record
Stat / Phone Orders (1)
Stat Orders
• Document any single dose orders in this section
• The prescriber must verbally inform the nurse responsible
for the patient’s care of any stat orders
Stat / Phone Orders (2)
Phone Orders
• For Phone Orders nurses document:
the Date the order is received
the Name of insulin
the dose (as a whole number)
Date / time the dose is to be administered
‘phone order’ and the name of prescriber
the initials of the nurses who received the order
• A second nurse must read back the written order to the doctor to confirm
and then countersign the phone order
• The nurses receiving the phone order must check to see if the stat / phone
order replaces, or is in addition to, other insulin orders
• Phone orders should be signed by the prescriber within 24 hours
• The nurse also cross references the phone order in the Routine Insulin
Insulin Administration
• If clinical judgement indicates that a prescribed
dose should not be administered, notify the
prescriber or on-call doctor to review
• Write the code W for withheld and document the
reason and the action taken in the clinical record
Administering Routine Insulin
• Mealtime insulin doses are given immediately before the patient eats
• Contact prescriber or doctor on-call if the patient has been receiving insulin
and there is not a dose ordered for a meal / time
• Calculate, prepare, check and administer dose in line with facility procedure
• Document the time given
• Document the dose administered in the row against the correct Name of
routine insulin row in the Administration Record
• Initial to acknowledge administering the dose
• Patients may have additional orders for the same time - check for
Supplemental and Stat / Phone insulin orders
• Example next slide
Administering Supplemental Insulin
• Review supplemental insulin order and current BGL to
determine if supplemental dose is required
• Calculate total insulin dose required
– May be in addition to routine insulin dose
• Prepare, check and administer total insulin dose
• Document the time given
• Document the doses or routine and supplemental insulin
separately in the Administration Record
• Initial to acknowledge administration of the dose
• Example next slide
Administering Stat/ Phone Orders
• Prepare, check and administer dose
• Document the time given
• Document the dose of stat / phone insulin
administered in the row against the
corresponding name of Routine insulin
• Sign as having administered the dose
• Cross reference phone orders in the Routine
Insulin Orders section
• Example next slide
Comments Section
• For the documenting communication between
members of the treating team with regard to
insulin therapy and diabetes management
• Examples of what to document here include:
– Doctor has been notified of the BGL
– hypoglycaemic event has been treated
– patient changed to intravenous insulin.
Pharmacy Review
• The clinician undertaking the pharmacy review
will sign this section as a record that they have
reviewed the insulin form (on the corresponding
day) to ensure that all insulin orders are clear,
safe and appropriate for that individual patient,
therefore reducing the risk of an adverse drug
Guidelines for Managing
Hyperglycaemia Alerts
Have been included to assist
inexperienced and non specialist
clinicians with management of
hyperglycaemia in hospital
inpatients. They provide
information related to:
 assessment required when
called for a Hyperglycaemia Alert
 initiation of basal and mealtime
insulin and adjustment of insulin
 suggested stat and
supplemental doses based on
weight or previous total daily
Management of Hypoglycaemia
in Diabetes - Adult
• Has four treatment pathways:
conscious and cooperative
insulin infusion
nil by mouth or nil by tube
oral or tube fed
• Appropriate food choices are listed
– Food choices should be centrally located
in each ward / unit / outpatient facility
– Each unit should have access to glucose
50% intravenous 50mL and glucagon 1mg
injection to use in emergency situations
– Glucose based products are preferred as
initial treatment
– Non diet products must be used to treat
Larger example next slide
Management of Hypoglycaemia
in Diabetes - Adult
Diabetes treatment review after
• Below the flowchart are guidelines for
Diabetes treatment review following treated
• Diabetes management must be reviewed in response to
a hypoglycaemic event
This work was developed by Medication Services
Queensland of Queensland Health and is based
on the user guide developed to support the State
Insulin Subcutaneous Order and Blood Glucose
Record for adults.