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HELP! Need help with documentation of blood sugars and sliding scales.

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by CapeCodMermaid CapeCodMermaid (Member)

CapeCodMermaid has 30+ years experience and works as a DNS.

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Here is the condensed version- Survey in May. Got tagged because nurses didn't properly document sliding scale insulin given. Re-inserviced everyone 3 times. Audit the charts and the MAR. DPH in today on a family complaint. Sliding scales not properly documented on this resident. What is wrong with these nurses? It's not rocket science. Do any of you have a special med sheet or extra form you use for sliding scales? I am at my wits' end.

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5,606 Visitors; 314 Posts

We have a blue sheet in the MAR for documenting blood sugars and insulin coverage (there is also a red sheet that is used for coumadin only). It has a line for every day of the month and four columns (for up to four blood sugar checks per day). For each blood sugar check each day we write the time, the blood sugar reading, how many units of sliding scale insulin were given for coverage and then our initials. There is a check box that needs to be checked if the MD was notified (if the blood sugar was very low or very high, etc.) There is a spot for the sliding scale order itself at the top of the sheet.

We then also have to document in the MAR. All our "diabetic orders" are required to be grouped together on one MAR sheet and "diabetic orders" is stamped on the top in red. There it lists when each accucheck is due, the sliding scale orders, what the blood sugar was and how much insulin was given. Also lists if there is any scheduled insulin.

So, essentially, we document the exact same information twice, but the MDs like for us to pull the blue sheets and leave them out for them when they're reassessing insulin orders, they get all the info. for the whole month condensed in one spot. We've never had any issues with the state with this method.

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PammyRN,CEN has 19 years experience.

3,894 Visitors; 78 Posts

I am in Ohio and IN

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PammyRN,CEN has 19 years experience.

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I am in Ohio and at my facility the Dr only uses sliding scale for no longer than 14 days. State will cite here F tag.....so he adjusts their insulin and d/c's the sliding scale.

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CapeCodMermaid has 30+ years experience and works as a DNS.

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That makes a lot of sense. We have residents who have their blood sugars checked only once or twice a week with a sliding scale!! I guess the other 5 or 6 days no one cares about their blood sugars.

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wyogypsy works as a RN.

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We have all of our insulins grouped together on 1-2 pages, depending on how long their sliding scale is. Each sliding scale dosage, i.e. 150-199 = 2 units, goes on only one line of the MAR, just like one med would go on one line. When we give sliding scale we then only have to find the right section for that blood sugar and put the time, what the blood sugar was, and our initials. We do not have to document it anywhere else.

What I have found that works better than inservicing is to give each nurse an audit form and have them audit each other for their sliding scales. They don't have to do a lot, just 3-5 each week which should only take them a few minutes. By doing this it will remind them what they themselves aren't doing, and they won't want anyone to catch their mistakes so they take care of it to begin with.

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CoffeeRTC has 25 years experience and works as a RN LTC.

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When the MARs are printed from the pharmacy, all of the diabetic orders are on the same page.

The order is on the left then we write in the next column..inital, blood suger, units and site. This gets writtn in daily. Each time has its own section.

How could they not be documenting this if it is on the MAR?\

I wouldn't make an other form up just because some nurses are lazy.

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debRN0417 has 31 years experience and works as a Lifelong RN working toward retirement maybe someda.

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My friend who is a Dietician and Certified Diebetic Educator says (now I know shes not a doctor but has a lot of experience) that sliding scale is pretty much becoming a thing of the past because most are heading toward doing periodic HgA1c's and starting folks on oral meds and diet controls or with once or twice a day injections if oral meds or diet is not possible or successful. I know that doesn't solve your immediate problem but food for thought.

I have found that the more places you ask people to document, the less the chance of them documenting. Most places that have the most success only document one place, and one place only. The have a seperate page of the MAR that has only the insulin orders and blood sugars on it. The blood sugars are not put anywhere else, unless there is a hypoglycemic reaction and glucagon was administered, then there was a nurses note documenting that and that the MD was notified, or whatever. Many, many folks have blood sugars checked only a couple times a week anymore. Unless they are a new diabetic or really brittle QID blood sugars are not being done. Rarely do I see sliding scale anymore. If they only document onleplace, then at the end of the shift it is so much easier to ensure that they have documented versus trying to make sure it is in all those other places. Alot of physicians start them on a sliding scale, and after two weeks they request all the blood sugars and adjust the insulin. Then after one more week, they do it again and D/C the sliding scale as soon as the blood sugars are controlled by the once or twice a day administration of the long acting insulins. Same thing with vital signs. If they have to document them in several places, it never happens. BUT if you have them documented in more than one place and on one day the blood sugar was not on the MAR, but on the fingerstick record (or whatever you call it) hopefully your surveyors would have enough sense to look at both documents. I don't know how you could be cited if it was at least on one place or another.

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3,419 Visitors; 82 Posts

My facility was cited a F tag for just this very thing. I don't get how nurses can't follow a simple sliding scale. I can't believe this is an issue but it is. We require nurses to verify with another nurse now all insulin sliding scales given. State takes this very serious. I think it boils down to carelessness. Nurses are in such a hurry they aren't paying attention.

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ssmandile has 30 years experience and works as a Clinical Nurse Manager.

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I agree with another post that sliding scale insulin is becoming a thing of the past, we do baseline blood sugars on our new diabetic admits, just to get an idea of where they are, and then usually DC the sliding scale altogether especially if they are not getting ac and HS blood sugars, what is the point and order HgbA1C's and the Docs will adjust daily insulin dosages. We have been getting really good results in blood sugar control for most of our residents, there are still a few that require more tweaking. As far as nurses documenting properly, and leaving holes on the MAR, if anyone has some ideas I would like to know as well, we have tried all the pre-printed sheets for insulins, made up our own, thinking it was a forms problem, but you know if they don't put pen to paper, there will be holes in documentation. Our facility will be switching to an EMR system over the next year, I am hopeful.

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CapeCodMermaid has 30+ years experience and works as a DNS.

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This thread is a year old. I have solved the problem by making special blood sugar sheets on God awful lime green paper that no one can miss. Our docs refuse to change the way they do things.

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