Diabetes Educators Calgary Charting Guidelines

Current insulin doses are charted under Diabetes Management > Insulin Instructions. The previously recorded current insulin doses will pre-populate the fields. Record doses as of today - that is, reflecting any changes you are recommending.

Medications, including insulins, are entered as reported medications. Insulin dosing instruction are entered in "Insulin Instructions".

Entering insulin as an active medication

Viewing and Charting insulin doses

Dose adjustments for medications other than insulin

Insulin Instructions on the After Visit Summary (AVS)

If the patient is currently on insulin, someone might have entered it as an active medication already. As time goes on, this will become more likely. Check the Medication List to make sure that the correct insulin is listed as an active medication. The insulin should be listed, with the direction to "Take as directed".

If not already listed as an active medication, add it, according to the appropriate scenario:

Scenario 1 - the patient is already on insulin, but it is not recorded in the chart

Scenario 2 - the patient is starting insulin, and the prescriber enters the order in the chart

Scenario 3 - the patient is starting insulin, verbal order received

Scenario 4 - the patient is starting insulin, order is from external provider

Use the directions below for patients who are already on insulin, but it is not listed as an active medication in the chart. 

1. Verify in one of several ways:
   1. Paper referral indicates the patient is on insulin
   2. PIN data from Netcare (Use the link in the Storyboard to take you to the patient chart in Netcare.)
   3. Paper verification from pharmacy, brought by patient
2. Go to “Medication Review”, type in the insulin you’re looking for.
3. Click ‘Add’ or press <Enter>. If you get the message “No items found”, click ‘Database Lookup’. Select the insulin you need.
4. Consider adding the SmartPhrase “DCCCNoteToProviders” in the instructions text box.
5. Click 'Accept', then ‘Close’.
6. Go to the Diabetes Management tab, to chart the insulin doses. If Insulin Instructions don’t show up right away, try pressing <F5>. If they still don’t show up, try closing the chart and opening it again.

If the ordering provider enters the order for the specific insulin directly into the chart, and submits a referral for an insulin start from within CC. For a video demonstration, please open this link.

1. The educator sees that the patient is coming to start insulin.
   1. There may be a message entered as a Note in the Schedule that the patient is to start insulin.
   2. The actual order to start insulin is viewed under Chart Review > Referrals.
   3. Starting doses are indicated in the referral and might be entered in Insulin Instructions (Diabetes Management > Insulin Instructions)
2. Charting is done following the usual charting procedures. Make note of the following specific guidelines:
   1. Reason for Visit (Rooming Tab) = Insulin start
   2. If you are providing a sample of insulin, chart the lot number and expiry date in your free text note.
   3. If not already done by the MD, chart the insulin doses under Diabetes Management tab > Insulin Instructions

Educators at DCC may accept verbal/telephone orders from internal prescribers. Verification with a signature or email order is required ideally within a week. For a video demonstration, please open this link.

1. Receive the verbal/telephone order.
2. Confirm that the physician is not able to enter the order directly at the time. Read back the order.
3. If you are with the patient, use the current open encounter. If you are not with the patient, Create an Encounter > Documentation. 
4. Click on 'Add Order' at the bottom of the patient chart. 
5. Search for and choose the correct insulin.
   1. Note that the initial search for the insulin is searching your Preference List. For dietitians especially, the insulin will not appear on your first search. Go to the top right, and click on Facility List, then Database.
   2. When the correct insulin is found, click on ‘Select and Stay’ at the bottom (so that it will be on your Preference List the next time you search), then Accept.
6.  In the dialogue box that comes up:
   1. Click the ‘Use Free Text’ button, near the top.
   2. For dispense Quantity, enter 1 pen/cartridge/vial. Refill = 0 if starting patient on insulin and dispensing. 
   3. Under Patient Sig enter ‘Take as directed’.
   4. For Class, specify ‘No Print’. This is very important, to make sure that a prescription is not printed at the pharmacy.
   5. Click Accept.
7. Click ‘Sign Order’ at the bottom right.
8. In the dialogue box that opens:
   1. Specify Order mode = ‘Verbal with readback’ or ‘Telephone with readback’.
   2. Ordering Provider: Search for and select the physician who ordered the insulin.
   3. Authorizing Provider: Search for and select the physician who ordered the insulin.
   4. (Note that the authorizing provider will get an In Basket message to confirm and co-sign the order.)
9. Click Accept.
10. Charting is done following the usual charting procedures. Make note of the following specific guidelines:
    1. Reason for Visit (Rooming Tab) = Insulin start
    2. If you are providing a sample of insulin, chart the lot number and expiry date in your free text note.
    3. Chart the insulin doses under Diabetes Management tab > Insulin Instructions

If a physician is not using Connect Care, and sends a fax or written order to start insulin, the order will be attached to the patient chart using Media Manager. The DCC educator will enter the order into Connect Care as described in Scenario 3 above, except that 'Transcribed from paper' is chosen. If the 'Authorizing Provider' is not available in Connect Care, use 'Provider Not in System' and submit a request to have the provider added. For a video demonstration, please open this link.

Step-by-step:

1. The educator sees that the patient is coming to start insulin.
   1. There should be a heads-up message that the patient is to start insulin entered as a Note in the Schedule.
   2. The actual order to start insulin is viewed under Chart Review > Media Manager (or > Referrals)
2. Review the order.
3. Click on 'Add Order' at the bottom of the patient chart. 
4. Search for and choose the correct insulin.
   1. Note that the initial search for the insulin is searching your Preference List. For dietitians especially, the insulin will not appear on your first search. Go to the top right, and click on Facility List, then Database.
   2. When the correct insulin is found, click on ‘Select and Stay’ at the bottom (so that it will be on your Preference List the next time you search), then Accept.
5.  In the dialogue box that comes up:
   1. Click the ‘Use Free Text’ button, near the top.
   2. For dispense Quantity, enter 1 pen/cartridge/vial. Refill = 0.
   3. Under Patient Sig enter ‘Take as directed’.
   4. For Class, specify ‘No Print’. This is very important, to make sure that a prescription is not printed at the pharmacy.
   5. Click Accept.
6. Click ‘Sign Order’ at the bottom right.
7. In the dialogue box that opens:
   1. Specify Order mode = ‘Transcribed from paper’.
   2. Ordering Provider: Search for and select the physician who ordered the insulin. If they are not in Connect Care, select yourself as ordering provider.
   3. Authorizing Provider: Search for and select the physician who ordered the insulin. If they are not in Connect Care, use ‘Provider Not in System’. Submit a ticket to have the provider added. In the mean time, under Wrap Up Tab > Communication, instead of PCP choose "Free Text" and carefully input the MD info including fax.
8. Click Accept.
9. Charting is done following the usual charting procedures. Make note of the following specific guidelines:
   1. Reason for Visit (Rooming Tab) = Insulin start 
   2. If you are providing a sample of insulin, chart the lot number and expiry date in your free text note.
   3. Chart the insulin doses under Diabetes Management tab > Insulin Instructions

To view insulin doses from your schedule:

• Single-click on a chart. A quick view of the patient, called SnapShot, opens (at the bottom or right side, depending on how you have it configured)
• Right-click on the down arrow at the right, and select “Add or remove buttons from toolbar”. Type in “Insulin…” and then <tab>. Select “Insulin Instructions”, then Accept.
• Click on the new button you just added to see a quick view of insulin doses, without needing to open the chart.

Current insulin doses should be charted under Diabetes Management > Insulin Instructions. Be aware that there are providers on Connect Care who are still not aware that this is where insulin doses should be charted. Consider using the Smart Phrase ".DCCCNoteToProviders" in the 'Instructions' free text box, to help inform others of where to find insulin doses.

The previously recorded current insulin doses will pre-populate the fields. Record doses as of today - that is, reflecting any changes you are recommending. For a video demonstration, please open this link.

Hold orders are indicated within the table, by entering "Hold until <xvz>"

Step-by-step:

1. Check the Medication List to make sure that the correct insulin is listed as an active medication. The insulin should be listed, with the direction to "Take as directed". If the insulin is listed with an incorrect dose, click on 'Not taken as listed', and enter the dose you are recommending as of today, AND chart doses as described in the following directions.
2. If the insulin you need is not listed as an active medication, follow the appropriate scenario above. As a last resort, if you aren’t able to have the correct insulin show up as an active medication, skip the following steps and document in the free text note.
3. Update doses in the "Insulin Instructions" section:
   1. Go to the Diabetes Management tab > Insulin Instructions (Note that if the insulin was only just added as an active medication, Insulin Instructions sometimes can't be found here. Try refreshing the chart by pressing <F5>) 
   2. If that doesn't work go to Chart Review tab > Medications (click arrow to open medications in new tab; find "insulin instructions" in blue and click arrow beside that to open new tab) 
4. Doses and Settings the patient was on at the time they arrived will pre-populate (if they were entered in CC prior to the visit). Modify any of the insulin instructions to reflect what you are recommending as of today.
5. Choose the appropriate instruction category: Mealtime Instructions, Fixed Dose Instructions, Pump Settings:
   1. Mealtime Instructions
      1. Choose the bolus insulin, if there is more than one to choose from.
      2. Instructions are entered in table format.
      3. Enter each mealtime separately, if needed, or specify “All meals”.
      4. Enter carb ratio (g carb per unit of insulin), sensitivity factor and BG target, as appropriate.
      5. Click “Accept” when done.
   2. Fixed Dose Instructions
      1. Choose the basal insulin (or bolus insulin, if the patient is taking fixed meal doses).
      2. Instructions are entered in table format.
      3. Enter Time of Day. You might use a clock time, or a descriptor, e.g. Breakfast or HS.
      4. Enter the fixed dose.
      5. Click “Accept” when done.
   3. Pump Settings
      1. There should be no need to choose the insulin, since the patient will be on rapid only.
      2. Instructions are entered in 4 tables: basal rates, Carb Ratio (g carb per unit of insulin), Sensitivity Factor, Glucose Target.
      3. Time of Day. You may enter military time, e.g. 1400, and CC will convert it automatically to 2:00 PM
      4. Enter the correct settings.
      5. Click “Accept” when done.

Department Smart Phrases will automatically reflect the current doses/settings in your note, without any need to double-chart.

“Insulin Instructions” should not be used to chart Metformin dosage changes. This is a system-wide feature, and is built for insulin only.
Use “Medication Review”

• For RDs this is under the "Nutrition Care" tab
• For RNs this is under the "Rooming" tab

Scenario 1:

The patient reports taking a different dose, and you’re not sure who (if anyone) advised that the patient take the different dose. You then click “Taking Differently”, and document the dose the patient is taking.

Scenario 2:

There are clear instructions from the MD regarding titrating the dose. In this case:

• Add the new order at the bottom.
• Create a new order with the new dose.
• You get a pop-up letting you know that there is a duplicate medication. Discontinue the medication record with the old dose. Discontinue reason = Dose Adjustment.
• Authorizing Provider = the MD who provided the order.