/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98196-en.cckm

201706160

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

ED/IP – Diabetes Management without Pump – Adult – Supplemental [3140]

ED/IP – Diabetes Management without Pump – Adult – Supplemental [3140] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


ED/IP - Diabetes Management Without Pump - Adult - Supplemental [3140]
Intended for Adult Patients Only
Patient Care Orders
Nutrition [30245]
Diabetes Meal Plan [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
Bedside Meal Instructions:
Room Service Class:
Nutrition [195356]
Diet - Diabetes Meal Plan [NUT0030] EFFECTIVE NOW, Starting today, Routine
Diet Type: Diabetes Meal Plan
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Non-Categorized Patient Care Orders [97411]
Glucose, POC [IPGLUCOSE] BEFORE MEALS AND BEDTIME, Starting today,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] EVERY 6 HRS IF NPO/ CONT. TUBE FEEDING/ OR
TPN, Starting today, Routine, Glucose, POC should
always be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] CONDITIONAL - RN COLLECT, Starting today,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition? 30 minutes before
start of cyclic tube feeding and 6 hours after initiation
Glucose, POC [IPGLUCOSE] SUPPLEMENTAL CHECK AT 0200, Starting today,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Non-Categorized Patient Care Orders [195357]
GLUCOSE, POC [GLUCPOC] BEFORE MEALS AND BEDTIME, Routine
If Conditional, What Condition?
GLUCOSE, POC [GLUCPOC] EVERY 6 HRS IF NPO/ CONT. TUBE FEEDING/ OR
TPN, Starting today, Routine
If Conditional, What Condition?
GLUCOSE, POC [GLUCPOC] CONDITIONAL - RN COLLECT, Routine
If Conditional, What Condition? 30 minutes before
start of cyclic tube feeding and 6 hours after initiation
Page 1 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

GLUCOSE, POC [GLUCPOC] SUPPLEMENTAL CHECK AT 0200, Starting today,
Routine
If Conditional, What Condition?
Medications - Insulin - NO Tube Feeding
Rapid Acting - Lispro (Single Response) [129853]
Insulin Lispro with Insulin to Carbohydrate Ratio
(Carb Counting) [225628]
Select Insulin to Carbohydrate Ratio (ICR)
STEP 1: Calculate the patient’s Total Daily Dose
STEP 2: Select corresponding ICR. (Enter Admin Instructions below)
STEP 3: Adjust ICR if glucoses remain >180 mg/dL.
Other Considerations:
• A custom ICR may be entered for pts with established regimen at home.
• RENAL INSUFFICIENCY/FAILURE: select a higher ratio to decrease hypoglycemia risk (e.g.,
if patient’s TDD is 40 units increase the ICR from 1:12 to 1:15
• BASAL INSULIN ONLY PTA (dose >/=40 units/day): select corresponding ICR using chart
above; then reduce basal dose by 25-50%.
Insulin to Carbohydrate Ratios- Adult (ICRs) URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97513-en.cckm
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection [53264]
0-30, Subcutaneous, 3 X DAILY (AT MEALTIME)
Insulin to Carbohydrate Ratio (ICR) {RXR INSULIN
TO CARBOHYDRATE RATIO (ICR):2000496}
Document carbohydrate grams eaten in Doc
Flowsheet.
Measure Carbohydrate Intake [NURDIE0016] CONTINUOUS, Routine, Document carbohydrate
grams eaten in Doc Flowsheet
insulin lispro - Note: Snack carbohydrate
counting dose [53264]
0-30, Subcutaneous, PRN, For snacks > 30 g
Insulin to Carbohydrate Ratio (ICR) {RXR INSULIN
TO CARBOHYDRATE RATIO (ICR):2000496}
Document carbohydrate grams eaten in Doc
Flowsheet
Insulin Lispro with Provider Determined Dosing
[145586]
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - BREAKFAST [53264]
Subcutaneous, 1 X DAILY
Hold dose if patient NPO. Give half dose if patient
eating < 50% of meal. Give within 15 minutes of
breakfast
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - LUNCH [53264]
Subcutaneous, 1 X DAILY (NOON)
Hold dose if patient NPO. Give half dose if patient
eating < 50% of meal. Give within 15 minutes of
lunch
Total Daily Dose (TDD)
(total amount of scheduled basal
and nutritional insulin doses in 24
hours)
Insulin to Carbohydrate Ratio
(ICR) (1 unit insulin covers ____
grams of carbohydrate)
15 - 29 units 1 unit:20 grams
30 – 39 units 1 unit:15 grams
40 – 49 units 1 unit:12 grams
50 – 59 units 1 unit:10 grams
60 - 89 units 1 unit:8 grams
90-119 units 1 unit:5 grams
> 120 units 1 unit: 4 grams
Page 2 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - DINNER [53264]
Subcutaneous, 1 X DAILY (PM)
Hold dose if patient NPO. Give half dose if patient
eating < 50% of meal. Give within 15 minutes of
dinner
Insulin Lispro with Patient Controlled Dosing
[129169]
Measure Carbohydrate Intake [NURDIE0016] CONTINUOUS, Routine, Document carbohydrate
grams eaten in Doc Flowsheet
insulin lispro (human) 100 UNIT/ML injection -
Patient Controlled Dose [53264]
0-30, Subcutaneous, 3 X DAILY (AT MEALTIME)
Patient determined dose of insulin lispro given
subcutaneously with meals using ***
Document carbohydrate grams eaten in Doc
Flowsheet
Intermediate-acting - Isophane (NPH) [20040]
insulin isophane NPH (human) 100 units/mL
injection - MORNING [45417]
Subcutaneous, 1 X DAILY
Administer in morning
insulin isophane NPH (human) 100 units/mL
injection - EVENING [45417]
Subcutaneous, 1 X DAILY (PM)
Administer in evening
insulin isophane NPH (human) 100 units/mL
injection - BEDTIME [45417]
Subcutaneous, 1 X DAILY (HS)
Administer at bedtime
Long-acting - Glargine [20041]
insulin glargine (LANTUS) 100 UNIT/ML injection
- MORNING [64829]
Subcutaneous, 1 X DAILY
Administer in the morning. Administer even if NPO.
Do NOT mix with other insulins
insulin glargine (LANTUS) 100 UNIT/ML injection
- NOON [64829]
Subcutaneous, 1 X DAILY (NOON)
Administer at noon. Administer even if NPO. Do
NOT mix with other insulins
insulin glargine (LANTUS) 100 UNIT/ML injection
- EVENING [64829]
Subcutaneous, 1 X DAILY (PM)
Administer in the evening. Administer even if NPO.
Do NOT mix with other insulins
insulin glargine (LANTUS) 100 UNIT/ML injection
- BEDTIME [64829]
Subcutaneous, 1 X DAILY (HS)
Administer at bedtime. Administer even if NPO. Do
NOT mix with other insulins
Self-Administration [20043]
Note: Patient to self-administer and determine
insulin per home regimen [950018]
4 X DAILY
Patient to self-administer and determine insulin per
home regimen
Note: Self Administered Medication Program
Documentation [950000]
ONCE
Correction Insulin - Daytime or Every Six Hours - LISPRO (Single Response) [20045]
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - DAYTIME 1-5 units [53264]
1-5 units, Subcutaneous, 3 X DAILY (AT MEALTIME)
For daytime hyperglycemia ONLY.
For blood glucose < 151 mg/dL give no additional
units;
For blood glucose 151-200 mg/dL give 1 unit;
For blood glucose 201-250 mg/dL give 2 units;
For blood glucose 251-300 mg/dL give 3 units;
For blood glucose 301-350 mg/dL give 4 units;
For blood glucose 351-400 mg/dL give 5 units.
Give even if NPO or meals skipped. Do NOT give
more often than every 4 hours when NPO.
Page 3 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - EVERY 6 HOURS 1-5 units [53264]
1-5 units, Subcutaneous, EVERY 6 HOURS
For hyperglycemia ONLY
For blood glucose < 151 mg/dL give no additional
units;
For blood glucose 151-200 mg/dL give 1 unit;
For blood glucose 201-250 mg/dL give 2 units;
For blood glucose 251-300 mg/dL give 3 units;
For blood glucose 301-350 mg/dL give 4 units;
For blood glucose 351-400 mg/dL give 5 units.
Give even if NPO or meals skipped.
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - DAYTIME 2-10 units [53264]
2-10 units, Subcutaneous, 3 X DAILY (AT
MEALTIME)
For daytime hyperglycemia ONLY.
For blood glucose < 151 mg/dL give no additional
units;
For blood glucose 151-200 mg/dL give 2 units;
For blood glucose 201-250 mg/dL give 4 units;
For blood glucose 251-300 mg/dL give 6 units;
For blood glucose 301-350 mg/dL give 8 units;
For blood glucose 351-400 mg/dL give 10 units.
Give even if NPO or meals skipped. Do NOT give
more often than every 4 hours when NPO.
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - EVERY 6 hours 2-10 units [53264]
2-10 units, Subcutaneous, EVERY 6 HOURS
For hyperglycemia ONLY
For blood glucose < 151 mg/dL give no additional
units;
For blood glucose 151-200 mg/dL give 2 units;
For blood glucose 201-250 mg/dL give 4 units;
For blood glucose 251-300 mg/dL give 6 units;
For blood glucose 301-350 mg/dL give 8 units;
For blood glucose 351-400 mg/dL give 10 units.
Give even if NPO or meals skipped.
Correction Insulin - Bedtime - LISPRO (Single Response) [20046]
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - BEDTIME 1-4 units [53264]
1-4 units, Subcutaneous, 1 X DAILY (HS)
For bedtime hyperglycemia ONLY
For blood glucose units;
For blood glucose 201-250 mg/dL give 1 unit;
For blood glucose 251-300 mg/dL give 2 units;
For blood glucose 301-350 mg/dL give 3 units;
For blood glucose 351-400 mg/dL give 4 units.
Give even if NPO.
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - BEDTIME 2-8 units [53264]
2-8 units, Subcutaneous, 1 X DAILY (HS)
For bedtime hyperglycemia ONLY
For blood glucose units;
For blood glucose 201-250 mg/dL give 2 units;
For blood glucose 251-300 mg/dL give 4 units;
For blood glucose 301-350 mg/dL give 6 units;
For blood glucose 351-400 mg/dL give 8 units.
Give even if NPO.
Medications - Insulin - WITH Tube Feeding
Long Acting - Glargine [190320]
requiring Type 2 diabetes. Patients with no history of -Use for patients with Type 1 or insulin
diabetes or use of medications or insulin for diabetes may NOT require long acting insulin for
tube feed coverage
Page 4 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

insulin glargine (LANTUS) 100 UNIT/ML injection
[64829]
Subcutaneous, 1 X DAILY
Administer even if NPO. Do not mix with other
insulins
Nutritional Insulin [20047]
insulin regular (human) 100 units/mL injection
[45422]
Subcutaneous, EVERY 6 HOURS
Give with tube feed. Hold if tube feeding off.
Notify provider if tube feeding stopped
[NURCOM0022]
CONTINUOUS, Notify provider immediately if tube
feeding is stopped unexpectedly (due to clogged tube
or for upcoming procedure/surgery) to place orders
for increased glucose monitoring and/or adjust insulin
or IV fluid order to avoid severe hypoglycemia from
active insulin
Cyclic Tube Feeding - NOTE: Suggested ratio 25% regular and 75% isophane (NPH) [20048]
Notify provider if tube feeding stopped
[NURCOM0022]
CONTINUOUS, Notify provider immediately if tube
feeding is stopped unexpectedly (due to clogged tube
or for upcoming procedure/surgery) to place orders
for increased glucose monitoring and/or adjust insulin
or IV fluid order to avoid severe hypoglycemia from
active insulin
insulin regular (human) 100 units/mL injection
[45422]
Subcutaneous, 1 X DAILY
Give 30 minutes prior to start of first cyclic tube
feeding of the day
insulin isophane NPH (human) 100 units/mL
injection [45417]
Subcutaneous, 1 X DAILY
Give 30 minutes prior to start of first cyclic tube
feeding of the day
Notify provider if tube feeding stopped
[NURCOM0022]
CONTINUOUS, Notify provider immediately if tube
feeding is stopped unexpectedly (due to clogged tube
or for upcoming procedure/surgery) to place orders
for increased glucose monitoring and/or adjust insulin
or IV fluid order to avoid severe hypoglycemia from
active insulin
Correction Insulin - Every Six Hours - REGULAR (Single Response) [144490]
insulin regular (human) 100 units/mL injection -
EVERY SIX HOURS - 1-5 Units [45422]
1-5 units, Subcutaneous, EVERY 6 HOURS
For hyperglycemia ONLY.
For blood glucose < 151 mg/dL give no additional
units;
For blood glucose 151-200 mg/dL give 1 unit;
For blood glucose 201-250 mg/dL give 2 units;
For blood glucose 251-300 mg/dL give 3 units;
For blood glucose 301-350 mg/dL give 4 units;
For blood glucose 351-400 mg/dL give 5 units.
Give even if NPO or meals skipped.
insulin regular (human) 100 units/mL injection -
EVERY SIX HOURS - 2-10 Units [45422]
2-10 units, Subcutaneous, EVERY 6 HOURS
For hyperglycemia ONLY.
For blood glucose < 151 mg/dL give no additional
units;
For blood glucose 151-200 mg/dL give 2 units;
For blood glucose 201-250 mg/dL give 4 units;
For blood glucose 251-300 mg/dL give 6 units;
For blood glucose 301-350 mg/dL give 8 units;
For blood glucose 351-400 mg/dL give 10 units.
Give even if NPO or meals skipped.
Medications - Hypoglycemia Treatment
Hypoglycemia Management [123771]
URL:
Page 5 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hypoglycemia Management (Adult) [191576]
Adult Hypoglycemia Treatment Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97511-en.cckm
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until
specified, Routine, Glucose, POC should always be
ordered in conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
Routine, Glucose, POC should always be ordered
in conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less
than 40 mg/dL), recheck glucose after 1 hour to
ensure glucose remains greater than or equal to
70mg/dL. After resolution of mild hypoglycemia
(i.e., glucose 40-69 mg/dL), consider rechecking
after 1 hour if patient has signs/symptoms of
hypoglycemia or is at risk for a subsequent
hypoglycemic event (e.g., previously administered
insulin still active, altered renal status, altered
mental status, NPO or interrupted nutrition, or any
other condition that increases hypoglycemia risk)
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose
less than 40mg/dL and patient able to eat/swallow
safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater.
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater.
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
40-69 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Page 6 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia
Algorithm
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely
AND has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia
Algorithm
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less
than 40 mg/dL and patient unable to eat/swallow
safely AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia
Algorithm
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting today For
7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting 6/16/17
For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Hypoglycemia Management [195358]
URL:
Hypoglycemia Management (Adult) [195359]
Adult Hypoglycemia Treatment Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97511-en.cckm
GLUCOSE, POC [GLUCPOC] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today, Routine
If Conditional, What Condition?
Page 7 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

GLUCOSE, POC [GLUCPOC] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
Routine
If Conditional, What Condition?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less
than 40 mg/dL), recheck glucose after 1 hour to
ensure glucose remains greater than or equal to
70mg/dL. After resolution of mild hypoglycemia
(i.e., glucose 40-69 mg/dL), consider rechecking
after 1 hour if patient has signs/symptoms of
hypoglycemia or is at risk for a subsequent
hypoglycemic event (e.g., previously administered
insulin still active, altered renal status, altered
mental status, NPO or interrupted nutrition, or any
other condition that increases hypoglycemia risk)
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose
less than 40mg/dL and patient able to eat/swallow
safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater.
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater.
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
40-69 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia
Algorithm
Page 8 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely
AND has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia
Algorithm
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less
than 40 mg/dL and patient unable to eat/swallow
safely AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia
Algorithm
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting today For
7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting 6/16/17
For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Laboratory
Obtain If Not Done Within Last 90 Days [143671]
HEMOGLOBIN A1C [HA1C] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Consults
Consults [104225]
Diabetes Consult Order Panel (Adult) [188497]
Diabetes Management Service : Will provide management or treatment recommendations for
patients with hyperglycemia and/or those who report outpatient use of insulin or other diabetes
medications. Patients should be expected to remain inpatient > 24 hrs from time of consult.
Consult is required for patients with insulin pumps or who use U-500 insulin. Consult Endocrine
for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education
(meter/insulin skills/other diabetes survival skills) for patients/families with knowledge deficits
and/or need for diabetes knowledge assessment. Recommended for all new diagnoses or
patients with A1C > 9.
Diabetes Education – Nutrition: Diabetes nutrition therapy including nutrition assessment,
carbohydrate education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio),
and/or individualized, nutritious meal planning for carbohydrates, portions, or considering other
comorbidities. Recommended for all new diagnoses or patients with A1C > 9
Page 9 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Consult Learning Center - Diabetes Education
(Adult) [CON0021]
ONCE, Routine, - If patient is newly diagnosed or is
new to insulin, provide 24 hours notice to allow
adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available
on Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on
weekdays and Pager 3276 on weekends.
- Learning Center staff are not available on
holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly
diagnosed and/or is new to insulin therapy, provide
24 hours notice to allow adequate time for nutrition
education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for
a patient who will be discharging that weekend,
please have the Paging Center contact the on-call
dietitian to help you facilitate the diabetes nutrition
education session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Follow-up Appointments - Required Documentation
discharge with a up appointment must be scheduled BEFORE -Joint Commission, a followPer
Complete the following orders as provider who will manage a patient's diabetes care.
the appropriate circumstance.appropriate to schedule and/or document
Follow Up Appointments - Diabetes (Single Response) [149021]
Joint Commission Requirement: Patients must have an appointment scheduled WITHIN 30
DAYS of discharge with a provider who will manage their diabetes care. Exclusions are allowed
based upon patient situation (e.g., discharge to skilled nursing facility, patient refusal, etc.).
Schedule Appointment with Provider to Manage
Diabetes [222085]
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Diabetes management
Which Provider:
Page 10 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Appointment scheduled (with provider who can
manage diabetes) [COR0064]
ONCE For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
(with provider who can manage diabetes)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge
with a provider who will manage a patient's
diabetes care (e.g., primary care physician,
endocrinologist, etc.) is a Joint Commission
requirement. Exclusions are allowed based upon
patient situation (e.g., patient discharging to a
skilled nursing facility, patient refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed
to request assistance in scheduling an
appointment.
Appointment scheduled per patient report
(ENTER DATE IN COMMENTS) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
per patient report (ENTER DATE)
Date of appointment (Month/Year):
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment pending: patient discharged on
weekend; follow-up information provided
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment pending:
patient discharged on weekend; follow-up information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 11 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Free clinic information provided [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Free clinic information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
discharging to a facility (e.g., skilled nursing facility,
correctional facility, etc.)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient refusal [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
refusal
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 12 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

No appointment: Patient does not have diabetes
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
does not have diabetes
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 13 of 13
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:37:55 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org