Point-of-Care Glucose Check & Hypoglycemia Treatment Note

Date/Time: [Auto-populated current date/time of documentation]

Location: [Unit/setting]

Author: [Name, role, credentials]

Protocol Authority: [Standing hypoglycemia protocol name/version / verbal order / telephone order] (Include ordering clinician name if verbal or telephone order)

Reason for Note: Documentation of point-of-care glucose check with hypoglycemia treatment and reassessment.

Indication & Initial Assessment

[Indication for glucose check: symptomatic patient-reported / symptomatic staff-observed / post-treatment recheck / scheduled-routine check / pre-insulin / pre-meal / other]. [Symptom description and approximate onset timing]. (If subjective symptoms reported, include brief patient quote. If patient unable to report symptoms, document "Unable to report symptoms due to [reason].")

(If treatment was given or glucose was below protocol threshold, include the following:)

• Level of consciousness: [alert / drowsy / obtunded / unresponsive]
• Ability to swallow safely: [safe / unsafe / unknown]
• NPO status: [NPO / not NPO]
• IV access: [present / not present]
• Vital signs: [Key vital signs measured at this time]

Glucose Values & Treatment Timeline

(Use collection time, not charting time. If any value is <40 mg/dL, obtain and document a confirmatory repeat within 5 minutes per CMS816 measure requirements. Continue checks at protocol intervals until stability target is reached.)

Time (collection)	Glucose (mg/dL) & Method	Context	Symptoms/Status	Intervention & Rationale
[HH:MM]	[Value] ([POC fingerstick / venous / lab-confirmed])	[Initial / Confirmatory repeat / Post-treatment recheck #1 / #2 / #n]	[Symptoms and clinical status at this time]	[Intervention type: Oral carbohydrate (grams and form) / IV dextrose (concentration and volume) / IM or IN glucagon (dose) / Insulin held or paused / Nutrition provided] — [Time administered] [Rationale linked to assessment] (e.g., "Alert with safe swallow—PO carbs given" / "NPO—IV dextrose given")
[HH:MM]	[Value] ([POC fingerstick / venous / lab-confirmed])	[Initial / Confirmatory repeat / Post-treatment recheck #1 / #2 / #n]	[Symptoms and clinical status at this time]	[Intervention if given] — [Time administered] [Rationale linked to assessment]
(Add additional rows as needed for each glucose check and intervention)

(If glucose value cannot be obtained, document reason and alternative actions taken.)

Severity Classification

• Hypoglycemia level: [Level 1 (<70 mg/dL) / Level 2 (<54 mg/dL) / Level 3 (severe, required assistance)] (Classify per organizational thresholds)
• Symptom status: [Symptomatic / Asymptomatic] at time of low value
• Severe event markers: [Required assistance / Seizure / Loss of consciousness / None]

Provider Notification

(If notification thresholds were not met, document "Provider notification not required per protocol" and omit the details below.)

• Trigger: [Value below threshold / Persistent low after treatment cycles / Altered mental status / Seizure / Recurrent episodes / Other]
• Notified: [Name and role] via [in-person / phone / secure message / pager] at [Time]
• Response received: [Orders or actions taken] at [Time]
• Rapid response/emergency activation: [Time and reason] (Only include if applicable)

Outcome

• Clinical response: [Symptom resolution status, mental status return to baseline]
• Final glucose: [Value] at [Time]; stability target [met / not met]
• Complications: [Nausea / Vomiting / IV infiltration / Aspiration concern / None]
• Disposition: [Remained on unit / Transferred / Continued observation / Discharged]

Contributing Factors & Prevention

(Include this section for recurrent or severe episodes; otherwise omit.)

• Suspected contributor(s): [Reduced oral intake or missed meal / NPO or procedure delay / Insulin-meal timing mismatch / Nutrition interruption / Medication dose or timing discrepancy / Increased activity / Other] (Label as suspected unless verified)
• Supporting observations: [Objective findings supporting suspected cause] (Notify appropriate parties per policy if medication discrepancy suspected; do not label as error unless verified)
• Prevention actions: [Insulin or medication held or adjusted / Nutrition plan modified / Monitoring frequency increased / Consult requested]

Signature

[Electronic signature: name and credentials]