Insulin Pump Start/Training Note

Date/Time: [Encounter date and time]

Start Type: [Saline Start / Insulin Start / Conversion (saline → insulin)]

Modality: [In-person / Telehealth]

Educator(s): [Name(s), role(s), credential(s)] (If unknown, enter "Unknown/Not documented")

Learners Present: [Patient / Parent/guardian / Caregiver(s) / Interpreter / Other] (List all present; if none besides patient, state "Patient only")

Diabetes Type: [T1D / Insulin-dependent T2D / Other]

Reason for Visit: [Brief summary of encounter purpose]

Clinical Context & Readiness

[Clinical basis for pump therapy and readiness assessment summary] (Include: current therapy immediately prior to start—if MDI, list basal insulin type, dose, and timing plus bolus method; if switching pumps, list prior manufacturer/model and reason for change. Document current glucose monitoring method. Provide estimated total daily dose (TDD) with data source noted. Include most recent A1c and/or CGM summary metrics if available. If baseline TDD is unknown, explicitly state which data sources were attempted and what was used instead.)

• Readiness Checklist:
  • Can check glucose: [Confirmed / Not confirmed]
  • Can recognize/respond to alarms: [Confirmed / Not confirmed]
  • Can deliver a bolus: [Confirmed / Not confirmed]
  • Can estimate carbohydrates or follow simplified dosing plan: [Confirmed / Not confirmed]
  • Understands hyperglycemia and ketone troubleshooting: [Confirmed / Not confirmed]
  • Knows how to contact clinic urgently: [Confirmed / Not confirmed]
• Barriers Assessed: [Vision / Dexterity / Cognitive / Health literacy / Language needs / Technology access / Housing/food insecurity / None identified] (List identified barriers and mitigation plan. If caregiver support required, document availability and role.)

Device & Technology

• Pump: [Manufacturer, model] | AID-capable: [Yes / No] | AID at start: [Activated / Deferred]
• CGM: [Manufacturer, model] | Integration with pump: [Integrated / Not integrated / Not applicable]
• Infusion Set: [Steel / Teflon] | Length: [Length or Unknown] | Insertion: [Manual / Inserter] | Site used today: [Anatomical location]
• Insulin: [Rapid-acting type] | Concentration: [U-100 / Other]
• Data Platform: [Upload method] | Clinic data sharing: [Enabled / Not enabled]

Training Session

Total education time: [Minutes] minutes

Teaching methods: [Demonstration / Written materials / Teach-back / Return demonstration / Simulation / Other]

Accommodations: [Interpreter / Low-vision instructions / Hearing accommodations / Caregiver as primary operator / None]

Competency Assessment

(For each topic, document whether taught, return demonstration status, and any comments. For safety-critical competencies not assessed, mark "Not assessed" with plan to complete before insulin delivery.)

Device Operation & Troubleshooting

Topic	Taught	Return Demo	Comments/Needs Reinforcement
Navigation/home screen	[Yes / No]	[Yes / No / Partial]	[Comments]
Lock/unlock	[Yes / No]	[Yes / No / Partial]	[Comments]
Charging/battery management	[Yes / No]	[Yes / No / Partial]	[Comments]
Reservoir/cartridge handling	[Yes / No]	[Yes / No / Partial]	[Comments]
Alarm response: occlusion, low reservoir	[Yes / No]	[Yes / No / Partial]	[Comments]
CGM signal loss/communication failures	[Yes / No]	[Yes / No / Partial]	[Comments]

Infusion Set Management

Topic	Taught	Return Demo	Comments/Needs Reinforcement
Site selection and rotation	[Yes / No]	[Yes / No / Partial]	[Comments]
Skin prep	[Yes / No]	[Yes / No / Partial]	[Comments]
Insertion technique	[Yes / No]	[Yes / No / Partial]	[Comments]
Priming/fill cannula	[Yes / No]	[Yes / No / Partial]	[Comments]
Securement and change frequency	[Yes / No]	[Yes / No / Partial]	[Comments]
Recognition of site problems	[Yes / No]	[Yes / No / Partial]	[Comments]

Insulin Delivery

Topic	Taught	Return Demo	Comments/Needs Reinforcement
Basal profile concepts	[Yes / No]	[Yes / No / Partial]	[Comments]
Temporary basal/activity modes; suspend/reconnect	[Yes / No]	[Yes / No / Partial]	[Comments]
Meal bolus and carb entry workflow	[Yes / No]	[Yes / No / Partial]	[Comments]
Correction bolus	[Yes / No]	[Yes / No / Partial]	[Comments]
Extended/square bolus	[Yes / No / N/A]	[Yes / No / Partial / N/A]	[Comments]
Bolus cancellation and insulin-on-board	[Yes / No]	[Yes / No / Partial]	[Comments]

AID-Specific

(Include only if AID activated; otherwise mark N/A)

Topic	Taught	Return Demo	Comments/Needs Reinforcement
Auto vs manual mode; requirements to stay in auto	[Yes / No / N/A]	[Yes / No / Partial / N/A]	[Comments]
Meal announcements and activity settings	[Yes / No / N/A]	[Yes / No / Partial / N/A]	[Comments]
Algorithm limitations; when to exit auto mode	[Yes / No / N/A]	[Yes / No / Partial / N/A]	[Comments]
Safety implications of missed meal boluses	[Yes / No / N/A]	[Yes / No / Partial / N/A]	[Comments]

Data Upload

Topic	Taught	Return Demo	Comments/Needs Reinforcement
Steps to upload and share with clinic	[Yes / No]	[Yes / No / Partial]	[Comments]
Early post-start metrics to review	[Yes / No]	[Yes / No / Partial]	[Comments]

Safety-Critical Items Not Assessed: [List any items marked "Not assessed"] (Document plan and timeline to complete before insulin delivery begins)

Initiation Procedure

Saline Start

(Complete only if Start Type is Saline Start; otherwise enter "N/A")

• Saline start date/time: [Date/time]
• Usual insulin regimen continued: [Yes / No] (Specify regimen if yes)
• Goals for saline phase: [Familiarization goals and competencies to achieve]
• Planned conversion date and prerequisites: [Target date and required competencies]

Insulin Start / Conversion

(Complete for Insulin Start or Conversion; otherwise enter "N/A")

• Date/time insulin placed in pump: [Date/time]
• First basal delivery time: [Time]
• Last long-acting insulin dose/time: [Dose, time / Unknown] (If transitioning from MDI. If unknown, document uncertainty and conservative safeguards used.)
• Transition plan: [Overlap strategy / Hold strategy] [Details]
• Verification: Correct insulin type [Confirmed]; Correct basal profile [Confirmed]; Safety limits [Confirmed]; CGM integration [Confirmed / N/A]
• First meal bolus supervised: [Yes / No / N/A] | Initial issues: [None / Description]

Initial Programmed Settings

(Document all parameters with units. Never leave dosing fields blank—use "Not programmed," "N/A," or "Deferred" with reason.)

Effective date/time: [Date/time]

Parameter	Value	Units
Basal rate(s) by time block	[Time blocks and rates]	U/hr
Insulin-to-carb ratio(s)	[Time blocks and ratios]	g/U
Correction factor/sensitivity	[Time blocks or single value]	mg/dL per U
Glucose target(s)	[Targets by time block if applicable]	mg/dL
Active insulin time	[Value]	hours
Max bolus limit	[Value / Not programmed / Deferred]	U
Max basal rate	[Value / N/A / Deferred]	U/hr
CGM alert thresholds	Low: [Value]; High: [Value]	mg/dL
Suspend features	[On / Off / N/A]	[Criteria if enabled]

AID System Parameters

(Include only if AID activated; otherwise enter "N/A")

• AID mode at start: [Enabled / Disabled / Deferred]
• User-configurable targets/activity modes: [Settings in use]
• Actions remaining manual: [Meal boluses / Exercise announcements / Other]

Ordering prescriber: [Name, credentials] (If unknown, enter "Unknown/Not documented")

Settings entered by: [Educator / Patient / Caregiver]

Protocol used: [Named protocol / None]

Conservative settings rationale: [Safety rationale if applicable]

Safety Education & Contingency Plans

(Document education provided and confirm understanding via teach-back for each area.)

• Hypoglycemia: [Signs/symptoms reviewed; individualized risk factors; treatment steps; rapid carb access confirmed; glucagon type prescribed and who trained; high-risk situations discussed]
• Hyperglycemia, Ketones, and DKA Prevention: [Rapid deterioration risk with infusion interruption emphasized; stepwise response plan reviewed—confirm glucose, assess site/pump, correction method by ketone severity, set change if not improving, hydration, escalation criteria; ketone check thresholds and frequency; injection may be required if ketones present or delivery suspect]
• Sick-Day Rules: [Continue basal; increased monitoring schedule; hydration/carb guidance when unable to eat; when to call clinic; ED criteria—vomiting, breathing difficulty, persistent ketones, dehydration, altered mental status]
• Pump Failure Backup Plan: [Injection dosing method; backup insulin and syringes/pens availability confirmed or plan to obtain; after-hours contact; ED criteria]
• CGM Failure Plan: [Manual mode operation; minimum SMBG frequency] (Include if CGM-dependent system; otherwise N/A)
• Written materials provided: [Yes / No] (If no, document reason and plan to provide)

Follow-Up Plan

• First touchpoint (24–72 hours): [Date/timeframe] | Method: [Phone / Portal / Telehealth / In-person] | Focus: [Items to review]
• First data review: Upload expected: [Date/time] | Reviewer: [Name/role]
• First comprehensive follow-up: [1–2 week target date]
• Settings adjustments: [Who can adjust and through what channel]
• Patient goals for week 1: [Independent site change / Upload frequency / Ketone supply access / Other]

Patient Understanding

[Attestation of patient/caregiver understanding] (Document teach-back confirmation for: hypoglycemia treatment, hyperglycemia/ketone response, pump failure backup plan. Note questions asked and answered. Document observed competencies specifically, e.g., "patient successfully performed supervised site change." Do not infer global competence from limited observation. If any safety-critical elements are missing—educator identity, modality, start type, prescriber authorization, ketone response competency, pump failure plan—mark as "Unknown/Not documented.")