Continuous Glucose Monitor (CGM) Initiation/Placement and Training Procedure Note

Date/Time: [Date and time of visit]

Location: [Clinic site or telehealth originating site]

Clinician: [Name, credentials]

Visit Type: [in-person / telehealth] (If telehealth, note that patient self-inserted sensor under real-time guidance.)

Service Summary

• CGM workflow type: [personal CGM start / professional CGM start / device change]
• Device system: [Manufacturer and model]
• Equipment source: [patient-provided / clinic-provided]
• CGM category: [real-time CGM / intermittently scanned CGM / implantable CGM]

Indication

[Diabetes type and therapy context, primary clinical rationale for CGM, reason for device change if applicable] (Include hypoglycemia risk factors, insulin regimen, pregnancy, or other relevant therapy context.)

Consent

[verbal / written] consent obtained. Risks reviewed including pain, bleeding, skin irritation, rare infection, and sensor inaccuracy. Alternatives discussed, questions answered, patient agreed to proceed.

Procedure

Device Identifiers: Sensor ID: [value or unavailable with reason]; Transmitter ID: [value or unavailable with reason]; Lot/Expiration: [value or unavailable]

Insertion: [Anatomic site and laterality]. Skin prepped with [prep agent]. Insertion performed per manufacturer instructions by [clinician / patient / caregiver]. Overpatch: [applied (type) / not applied]. Patient tolerance: [well tolerated / mild discomfort / significant pain]. Immediate complications: [none / bleeding controlled / other].

Activation: Paired to [receiver / phone app / both]. Warm-up initiated at [time]. Calibration: [factory calibrated—no calibration required unless prompted / calibration required per schedule].

Device Configuration

(Document actual threshold values. If using device defaults, state "defaults reviewed and accepted" and omit individual values.)

• Units: [mg/dL / mmol/L]
• Low alert threshold: [value]
• Urgent low threshold: [value]
• High alert threshold: [value]
• Rate of change alerts: [enabled with parameters / disabled]
• Alert schedule: [24/7 / nighttime only / custom schedule]
• Rationale for non-default settings: [rationale] (Include only if non-defaults selected.)

Data Management

• App/account: [new install completed / existing account used / deferred with plan]
• Clinic data platform: [enabled (platform name) / deferred until (timeframe)]
• Sharing configuration: [enabled with (relationship) / not enabled / deferred until (timeframe)] (Document patient permission obtained if sharing enabled.)

Training Completed

Topics covered:

• Sensor wear and site rotation: [completed / deferred]
• Reading display (current glucose, trend arrows, graph): [completed / deferred]
• Interpreting and responding to alarms: [completed / deferred]
• When readings may be unreliable (warm-up, compression lows): [completed / deferred]
• Sensor replacement procedure: [completed / deferred]
• Troubleshooting (signal loss, adhesive issues): [completed / deferred]
• When to contact manufacturer vs clinic: [completed / deferred]

Competency demonstration: [Teach-back demonstrated for key actions including treating lows, responding to urgent low alarm, and navigating app / partial—limitations and plan noted / not achieved—mitigation plan] (If not achieved, document limitations and plan such as additional training, caregiver involvement, or educator referral.)

Hypoglycemia Response Plan

• Treatment threshold: [value] (Typically ≤70 mg/dL.)
• Treatment instructions: [Fast-acting carbohydrate amount], recheck in 15 minutes, repeat if still low
• Glucagon and EMS: Use glucagon and call EMS if unable to take oral carbohydrate or altered mental status—[reviewed / not reviewed]
• Glucagon prescribed: [yes / no]; Caregiver trained: [yes / no / N/A]
• Driving/work safety counseling: [provided / not indicated]

Post-Procedure

Procedure [well tolerated / tolerated with discomfort]. Insertion site [clean, dry, intact / other findings]. Patch [intact / not applied]. Patient received instructions on wear period, replacement date [date], when to contact clinic, and follow-up requirements.

Follow-Up Plan

• Follow-up: [timeframe] via [in-person / telehealth / phone]
• Data review interval: [e.g., first 7–14 days]
• Upload instructions: [method and timing]; if upload fails: [contingency plan]

Professional CGM

(Include only when clinic-owned equipment is used; omit entirely for patient-owned personal CGM.)

• Planned wear duration: [total days] (minimum [value] days required)
• Removal: [clinic removal / patient self-removal] scheduled [date]
• Data retrieval: Download at [location/method] on [date]; interpreted by [clinician/team]
• Equipment return: [instructions if applicable]