BLOOD GLUCOSE FLOW SHEET
BLOOD GLUCOSE FLOW SHEET
BLOOD GLUCOSE FLOW SHEET
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HENRY FORDMACOMB HOSPITALS<strong>BLOOD</strong> <strong>GLUCOSE</strong> <strong>FLOW</strong> <strong>SHEET</strong><strong>GLUCOSE</strong> EVERY ________________________________<strong>GLUCOSE</strong> GREATER THAN __________CALL PHYSICIAN<strong>GLUCOSE</strong> LESS THAN _________ 70 TREAT PER PROTOCOL* See MAR for insulin ordersDATE TIME <strong>BLOOD</strong><strong>GLUCOSE</strong>METERDOSETYPENORMAL RANGESFASTING - 70 TO 110 MG/dLRANDOM - 110 TO 180 MG/dLLEGENDB = BASALC = CORRECTIONALP = PRANDIALINITIALS TIME ORAL AGENT/INSULINDOSE/TYPE/ROUTESAMPLEINITIALSInitial Signature/Title Initial Signature/Title Initial Signature/Title Initial Signature/TitleMR7643460 rev.08/11
HENRY FORDMACOMB HOSPITALS<strong>BLOOD</strong> <strong>GLUCOSE</strong> <strong>FLOW</strong> <strong>SHEET</strong><strong>GLUCOSE</strong> EVERY ________________________________<strong>GLUCOSE</strong> GREATER THAN __________CALL PHYSICIAN<strong>GLUCOSE</strong> LESS THAN _________ 70 TREAT PER PROTOCOL* See MAR for insulin ordersDATE TIME <strong>BLOOD</strong><strong>GLUCOSE</strong>METERDOSETYPENORMAL RANGESFASTING - 70 TO 110 MG/dLRANDOM - 110 TO 180 MG/dLLEGENDB = BASALC = CORRECTIONALP = PRANDIALINITIALS TIME ORAL AGENT/INSULINDOSE/TYPE/ROUTESAMPLEINITIALSInitial Signature/Title Initial Signature/Title Initial Signature/Title Initial Signature/TitleMR7643460 rev.08/11
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