RN Train-the-Trainer Course: Documentation Considerations
RN Train-the-Trainer CourseComplete all of the following modules:
Documentation Considerations
Maintaining accurate documentation of all diabetes care provided is important. Records should be securely maintained according to agency policy to ensure a person’s privacy and to meet other regulatory body requirements specific to the type of healthcare facility/school. The RN should maintain the following:
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Individualized healthcare plan or diabetes medical management plan (DMMP).
Examples: -
Emergency care plan.
Examples: - Diabetes care provided, items to consider including: blood glucose results, carbohydrates consumed, and insulin administered (see sample "Diabetes Documentation Log" form)
- Nurses and UDA notes of any care provided
- Description of any complications from medications and/or treatments
Diabetes Documentation Log |
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Day of Month |
BG/CHO* Breakfast |
Insulin Units |
BG/CHO* Lunch |
Insulin Units |
BG/CHO* Supper |
Insulin Units |
BG/CHO* Bedtime |
Insulin Units |
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*BG/CHO = BG stands for Blood glucose; CHO stands for carbohydrate
Other Action |
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| Date | Time | BG | Action | Initials |
| Print Name | Initials |