Insulin Pump or Automated Insulin Delivery Start Visit Note

Date/Time: [Date and time of encounter]

Patient: [Patient name / MRN]

Visit Type: [in-person / video / phone / hybrid]

Visit Stage: [device selection / training day / activation day / early follow-up]

Participants: [Patient, caregiver(s), interpreter, device trainer, clinician(s) present]

Data Sources Reviewed: [Device downloads, CGM reports, pump history, glucose logs, labs, external records reviewed]

Reason for Visit

[Patient-centered reason for visit: pump start / AID initiation / AID upgrade / pump replacement / transition from MDI] (For upgrades or switches, include why now: coverage change, device issues, glycemic concerns, quality of life, pregnancy planning.)

History of Present Illness

[Current insulin regimen and delivery method, approximate total daily dose, CGM/BGM use, and key glycemic patterns prompting change]

[Goals for technology: reduce hypoglycemia, improve time-in-range, reduce burden, overnight control] [Brief patient quote if it clarifies goals or concerns]

[Prior pump/AID/CGM experience and reasons for any discontinuation] [Readiness factors: carb counting skills, ability to respond to alarms, caregiver involvement] [Safety-relevant history: severe hypoglycemia, hypoglycemia unawareness, DKA history, adhesive reactions, infusion site issues, supply barriers] [Shared decision-making summary: options discussed, preferences, constraints including insurance, dexterity, vision, language needs]

Relevant Background

(Omit this section if no factors materially affect device choice, safety, or settings.)

• [Diabetes type, duration, relevant complications]
• [Comorbidities affecting glycemia or device safety: steroids, gastroparesis, pregnancy, dialysis schedule]
• [Allergies/sensitivities: adhesives, insulin]
• [Social factors affecting safe use: food access, work/school schedule, travel, storage, housing stability]

Objective

• Vitals: [Weight (required for dosing), BP, HR, height/BMI] (If telehealth, note patient-reported values or "Not obtained.")
• Skin Exam: [Inspection of infusion/injection sites for lipohypertrophy, lipoatrophy, scarring, dermatitis; dexterity/vision observations] (If not assessed, state reason.)
• Labs: [Most recent A1c with date] [Renal function or other labs only if impacting dosing or device safety]
• Device Data Summary: [CGM metrics: date range, % wear, TIR/TBR/TAR, GMI, notable patterns] [Pump data: TDD, basal/bolus distribution, prior settings if upgrading]

Device Selection and Rationale

Device(s) Selected:

• Pump/AID system: [Name and model]
• CGM: [Model and integration type]
• Infusion set: [Cannula type, length, tubing length] (Omit for tubeless patch pumps.)
• Insulin type for pump: [Rapid-acting insulin name]
• For upgrades: [What is changing from prior system]

Rationale:

• [Clinical reasoning: hypoglycemia reduction, TIR improvement, integration needs]
• [Patient preferences/constraints: wearability, alarm profile, vision/dexterity]
• [Coverage/affordability and supply considerations]

Start Logistics:

• [Planned activation date]
• [Who will perform activation]
• [Training modality: in-person / video / phone / hybrid]
• [Data-sharing platform and setup status]

Education and Training

(Clearly distinguish completed from planned/deferred training. Document only what was taught and demonstrated—do not infer competency.)

Training Completed Today:

• Trainer and methods: [Trainer name/credentials] [Methods: demonstration, teach-back, return demonstration, written materials, video modules]
• Topics covered: [Device fundamentals: reservoir/pod fill, priming, insertion, site rotation, set changes, troubleshooting] [AID-specific: automated vs manual modes, meal boluses, temp targets/exercise mode, delivery limits] [CGM integration: pairing, calibrations, alert management] [Data upload/sharing]
• Competency validation: [What patient/caregiver demonstrated: insertion, test bolus, acknowledging alerts, mode changes] (If demonstration not possible, document why and mitigation plan.)

Previously Completed: [Prior training topics, dates, source]

Planned/Deferred: [Topics for next session, planned date, reason for deferral]

Initial Settings

Status: [Programmed today / Planned for activation on (date)]

• Basal profile(s): [Rates and time blocks, or note if algorithm-determined with inputs used]
• Insulin-to-carbohydrate ratio(s): [Time blocks and ratios]
• Insulin sensitivity factor(s): [Time blocks and factors]
• Glucose/correction target(s): [Target values and time blocks]
• Active insulin time: [Duration]
• Maximum bolus limit: [Value]
• Alert settings: [Low glucose threshold, urgent low threshold, high glucose threshold]
• Special modes enabled: [Sleep mode, activity/exercise mode defaults]

Basis for Settings: [Prior pump settings carried forward vs changed; weight-based or MDI conversion; CGM pattern review]

Safety Planning

Backup Insulin Plan

• [Long-acting insulin prescription and dose if pump stopped >24 hours, with timing instructions]
• [Rapid-acting insulin via pen/syringe for corrections with dosing]
• [Confirmation patient has supplies and understands when to use]

Ketone and Infusion Failure Plan

• Suspect infusion failure when: [Persistent hyperglycemia despite correction, repeated alarms, unexplained rising glucose]
• Ketone testing: [When to check with glucose/time thresholds] [Blood vs urine method]
• Actions if ketones present: [Hydration, immediate set/pod change, correction by injection (not pump), recheck interval, when to seek emergency care: vomiting, abdominal pain, rapid breathing, altered mental status]
• [Ketone testing supplies confirmed available]

Hypoglycemia Plan

• [Recognition and treatment: fast-acting glucose source, amount, retest timing]
• [Glucagon availability, location, and who is trained to administer]
• [Special considerations: driving, exercise, alcohol, work/school]

Supplies Confirmed

[Extra infusion sets/pods, extra insulin, ketone strips/meter, batteries/charger, adhesive supplies, glucose tabs, glucagon]

Follow-up and Data Review Plan

Initial Follow-up Schedule:

• [First check-in: timing, modality, responsible team member]
• [Next clinic/telehealth visit]
• [Expected frequency of setting adjustments in first month]

Data Sharing:

• [Platform used, sharing status: active / pending]
• [Data review windows: first 72 hours, first 14 days]
• [Triggers for outreach: recurrent lows, sustained highs, automation off time, site failures]

Patient Communication: [How to contact clinic, expected response time, after-hours escalation]

Orders

(Include only orders placed or renewed today.)

• [Pump/AID supplies: sets, pods, reservoirs]
• [CGM supplies: sensors, transmitters]
• [Insulins: pump rapid-acting, backup long-acting]
• [Ketone testing supplies]
• [Glucagon]
• [Referrals: diabetes education, nutrition, behavioral health, school orders]

Assessment and Plan

[Summary assessment: diabetes context, device/therapy initiated or planned, key safety measures in place, follow-up timeline] (Include any prerequisites not yet met and the interim plan. If activation deferred, document what is missing, why it matters, interim regimen, and when activation will occur.)