Document the diabetes-specific skilled surveillance and management each day:
Blood-glucose values and the trend against the ordered parameters and the sliding-scale/titration order; insulin administered (type, dose, site) and the response.
Hypoglycemia signs (diaphoresis, tremor, confusion) and hyperglycemia signs (polyuria, thirst, lethargy); intake and activity relative to the insulin plan; and, when relevant, ketones.
Diabetic complications on the skilled radar: foot skin/perfusion (route wound detail to Skin) and renal status (route to Genitourinary/Renal).
MDS-supportive data
Insulin days and the number of insulin injections are coded in MDS Section N, IV medication in Section O, a diabetic foot ulcer in Section M, and the diabetes diagnosis in Section I. The record must document the glucose values, insulin administration, and response so the MDS is supported.
