Toolkit for Implementing the Chronic Care Model in an Academic Environment

Ambulatory Insulin Titration Form

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 ____________________________________________________________

Date AM Blood Sugar Lunch Blood Sugar PM Blood Sugar HS Blood Sugar
Fasting Post Pre Post Pre Post
               
               
               
               
               
               
               
Total              
Average              

Glargine (Lantus) Titration

Glargine Dose/Titration Units
Average Fasting Sugar  
Current Glargine Dose ____ Units
Glargine Titration ____ Units
New Glargine Dose ____ Units


Aspart (Novolog) Titration

 
Aspart Dose/Titration Units
Breakfast Lunch Dinner
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
80-99 maintain 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
100-119 maintain 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

Return to Document

Page last reviewed October 2014
Internet Citation: Ambulatory Insulin Titration Form. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/chroniccaremodel/chronic3a11b.html