Ambulatory Insulin Titration Form

Toolkit for Implementing the Chronic Care Model in an Academic Environment

Each of the four pilot sites adapted the basic concepts underlying the planned visit approach to meet the unique needs of the team and patient population. The Hoxworth Internal Medicine team generated an important change with its Ambulatory Insulin Titration Form.

 

 

THE UNIVERSITY HOSPITAL

Progress Notes

Ambulatory Insulin Titration Form

Name _____________________________

MRN _____________________________

DOB _____________________________

Phone Number _____________________________

 TUH-00, Rev. 8/061

Primary Care Doctor ____________________________________________________________

DateAM Blood SugarLunch Blood SugarPM Blood SugarHS Blood Sugar
FastingPostPrePostPrePost
        
        
        
        
        
        
        
Total       
Average       
Glargine (Lantus) Titration
Glargine Dose/TitrationUnits
Average Fasting Sugar 
Current Glargine Dose____ Units
Glargine Titration____ Units
New Glargine Dose____ Units

Aspart (Novolog) Titration

 
Aspart Dose/TitrationUnits
BreakfastLunchDinner
Current Aspart Dose   
 
Aspart Titration   
 
New Aspart Dose   
 
Fasting Blood Glucose average for at least 3 consecutive days (mg/dl)Adjust dose of glargine (Lantus), units
>180+8
160-180+6
140-159+4
120-139+2
100-119+1
80-99maintain dose
60-79-2
<60-4
 
Preprandial or Bedtime Blood Glucose average for at least 3 consecutive days (mg/dl)Adjust dose of aspart (Novolog) units
>180+3
160-180+2
140-159+2
120-139+1
100-119maintain dose
80-99-1
60-79-2
<60-4

Notes: _______________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

 

Adapted from: Ann Intern Med 2006;145:125-134.

Signature (RN/MD)_____________________________________Date___________Time___________

1. White Medical Records   Yellow Clinic Record

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Page last reviewed January 2008
Internet Citation: Ambulatory Insulin Titration Form: Toolkit for Implementing the Chronic Care Model in an Academic Environment. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/chroniccaremodel/chronic3a11b.html