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 ____________________________________________________________

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







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: _______________________________________________________________________________________________

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

Signature (RN/MD)_____________________________________Date___________Time___________

1. White Medical Records Yellow Clinic Record

Return to Document

Current as of 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