Assess glycemic status against the ordered parameters and document the skilled judgment:
Blood-glucose values and the trend against the ordered parameters and the sliding-scale/titration order; insulin administered (type, dose, site) and the response.
Signs of hypoglycemia (diaphoresis, tremor, confusion) and hyperglycemia (polyuria, thirst, lethargy); intake relative to the insulin plan (route nutrition detail to Nutrition).
For thyroid/electrolyte disorders, the relevant symptoms and the monitoring parameters and labs.
MDS-supportive data
Insulin days and the number of insulin injections are coded in MDS Section N; IV medication in Section O; the endocrine diagnosis in Section I. The record must document the glucose values, insulin administration, and response so Section N is supported.
