Traverse Bay Area Intermediate School District

1101 Red Drive, P. O. Box 6020

Traverse City, MI 49696-6020
INSULIN & BLOOD SUGAR DOCUMENTATION (231) 922-6200 FAX: (231) 922-6270
Student:
_______________________________________ Birthdate: ______________ Physician: ________________________________________www.tbaisd.k12.mi.us
School: ________________________________________ School Year: ____________ Witness: __________________________ Initials: _________
Teacher: _______________________________________ Initial: ________ Witness: __________________________________ Initials: _________
1 2 3 5 6 7
4 8 Glucometer Control Solution Test: Monthly_________________

left hand right hand Test strip expiration date: ________ ________ ________ ________
Coverage
Correction (B)
(BS minus Add
Blood Sugar Test before Lunch (A) Insulin dose correction Staff
AM 120) Carb (carbs ÷ plus
Date Insulin List food eaten for lunch count
Initials
Snack Every 40 give 10 = 1 unit) coverage
dose insulin dose (2)
Staff one unit (A) + (B)
Time Site: Results
initials !! Insulin dose

Insulin & Blood Sugar Documentation 2/2009

 ! If less than 50, give 8 oz of juice + 30gm
AS NEEDED BLOOD SUGAR TEST
protein/carb snack (8 peanut butter
crackers)
! If less than 70 give 15gm snack = 4 oz
juice and 15gm snack protein/carbs (6
peanut butter crackers) Signs of hypoglycemia Signs of hyperglycemia
! For a blood sugar less than 70, recheck ! hunger ! thirst
blood sugar in 15 minutes - if less than 70 ! weakness
BLOOD SUGAR BEFORE BUS ! frequent urination
give another 15gm carb snack and NO ! irritable
BUS, call mother ! increased hunger
! drowsy ! excessive talking & laughing
! If 70-90 give 15gm high carb snack (6 ! personality change ! vomiting
peanut butter crackers ! confusion ! dry mouth
! combative
! If 90-120 give light snack (3 peanut butter ! seizure
crackers)

! If greater than 280, give correction dose

to 120
Staff
Staff initials
Date Time Site Results
(2) Treatment if Needed Date Time Site Results initials Treatment if Needed
(2)

Insulin & Blood Sugar Documentation 2/2009