Insulin Administration Record Form
Record insulin administration details, blood glucose context, and follow-up notes for a patient’s insulin dose.
Patient & Record Details
Patient Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Record / Patient ID
Care Setting / Location
*
Please Select
Inpatient Unit
Outpatient Clinic
Emergency Department
Home Care
Long-Term Care Facility
Other
Date of Administration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Administration
*
Hour Minutes
AM
PM
AM/PM Option
Administering Staff Name / Role
*
Insulin Administration Details
Insulin Type / Name
*
Insulin Formulation
Please Select
Rapid-acting
Short-acting
Intermediate-acting
Long-acting
Premixed
Other
Dose Administered (units)
*
Route of Administration
*
Subcutaneous
Intravenous
Other
Injection Site
Please Select
Abdomen
Upper arm
Thigh
Buttock
Other
Dose Type
*
Scheduled
Correctional
Meal-related
Blood Glucose & Meal Context
Blood Glucose Reading
*
Glucose Check Time
*
Hour Minutes
AM
PM
AM/PM Option
Meal Status at Time of Administration
*
Before meal
With meal
After meal
Not meal-related
Carbohydrate Intake (g)
Reason for Dose Adjustment or Hold Decision
Monitoring, Response & Notes
Patient Response After Administration
*
No adverse reaction
Mild reaction
Hypoglycemia symptoms
Other
Adverse Effects or Incident Notes
Additional Instructions for Ongoing Care
Follow-up Required
*
Yes
No
Submit Record
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