Type 1 Diabetes Admission Note (New Diagnosis)

Date/Time: [Date and time of note entry]

Author/Role: [Author name and role]

Service/Team: [Admitting service/team]

Location: [ED / floor / ICU / step-down]

Historian(s): [patient / family / EMS / outside hospital / chart review]

Interpreter: [Yes / No] (If yes, specify language)

History Reliability: [good / fair / limited] (If limited, briefly explain reason)

Chief Complaint

[Chief complaint in patient's own words]

Clinical Urgency Snapshot

Primary Admission Diagnosis: [New-onset diabetes with or without DKA/HHS]

DKA/HHS Status: [suspected / confirmed / ruled out / pending workup] (Do not infer without explicit criteria.)

Level of Care: [ICU / step-down / floor] [Brief rationale]

Immediate Concerns:

• [Acidosis severity if applicable]
• [Mental status concerns]
• [Hydration status and hemodynamics]
• [Electrolyte abnormalities]
• [Infection concern or other precipitant]

History of Present Illness

[One-liner: age, key features, presenting syndrome, DKA/HHS status]

[Chronological narrative including: symptom timeline (polyuria, polydipsia, weight loss, fatigue, blurred vision); DKA symptoms if present (nausea, vomiting, abdominal pain, tachypnea, altered mental status); potential triggers (infection, access issues, medications, stressors); how diagnosis was made (point-of-care glucose, labs, ketones, A1C if known); ED or outside hospital course (fluids, insulin, electrolytes, transfers)] (Include pertinent negatives only if clinically meaningful. Use brief direct quotes only for key safety or access concerns.)

Focused Review of Systems

• Constitutional: [Fever, chills, malaise, weight change]
• GI: [Nausea, vomiting, abdominal pain]
• Respiratory: [Dyspnea, cough, tachypnea]
• Neurologic: [Headache, confusion, lethargy]
• GU: [Urinary symptoms if infection considered]
• Other relevant systems: [Only if directly related to differential]

Past History

Past Medical/Surgical History: [Medical and surgical history; note autoimmune conditions] (Often minimal in new diagnosis.)

Medications Prior to Admission: [Medication list with doses] (Include recent glucocorticoids; document "none" explicitly if applicable.)

Allergies: [Allergen and reaction type]

Family History: [Type 1 diabetes, thyroid disease, celiac disease, other autoimmune conditions; note type 2 diabetes separately]

Social History / Access Factors: [Insurance status; medication affordability; food security; housing stability; refrigeration and sharps disposal ability; caregiver support; health literacy; transportation] (Focus on factors affecting safe outpatient diabetes care.)

Physical Exam

(Document vitals separately; do not duplicate here.)

• General/Hydration: [Appearance, distress level, dehydration signs]
• Mental Status: [Alertness, orientation] (Note trends during treatment if DKA is present.)
• Respiratory: [Effort, tachypnea, Kussmaul breathing if present, oxygen requirement]
• Cardiovascular/Perfusion: [Heart rate and rhythm, pulses, capillary refill, orthostasis if assessed]
• Abdomen: [Tenderness, guarding, distension, bowel sounds] (Note if improves with treatment.)
• Infection Signs: [Pharynx, lungs, skin/soft tissue, other relevant findings]
• Other Focused Findings: [Additional relevant findings]

Objective Data

Vitals

• Triage vitals ([time]): [BP / HR / RR / Temp / SpO2]
• Current vitals ([time]): [BP / HR / RR / Temp / SpO2]
• Trends: [Brief summary if clinically relevant]

Laboratory Data

(Group by collection time; identify pending results explicitly. For critical values—weight, ketones, pH, bicarbonate, potassium—document as: known value, pending, or not obtained with reason.)

• [Collection date/time]:
  • Glucose: [POC value] / [Serum value]
  • A1C: [value / ordered / pending]
  • Ketones: [β-hydroxybutyrate value (preferred) or urine ketones result]
  • Acid-base: pH [value], HCO3 [value], anion gap [value]
  • Electrolytes: Na [value], corrected Na [value], K [value], Cl [value], CO2 [value], BUN [value], Cr [value], Phos [value], Mg [value]
  • Osmolality: [value] (Include if HHS considered.)
  • CBC: WBC [value], Hgb [value], Plt [value]
  • Infection workup: [UA, cultures, imaging results as obtained]
  • Pregnancy test: [result / pending / not obtained (reason)] (If applicable.)
  • EKG: [Relevant findings] (If obtained.)
  • Weight: [value / pending / not obtained (reason)]
• Repeat labs ([time]): [Key interval values]
• Pending labs: [Tests pending with expected timing]

Imaging

[Study type, date/time]: [Key findings] (Include only if performed and relevant.)

Diagnostic Criteria Summary

(Structured checklist with explicit values and timestamps for handoffs.)

Diabetes Diagnosis: Criterion met: [A1C ≥6.5% / random glucose ≥200 mg/dL with symptoms / hyperglycemic crisis]. Value: [value]. Date/time: [date/time]. [Confirmatory testing needed / waived due to crisis presentation].

Type 1 Classification Status: [confirmed / likely / uncertain]. Supporting features: [weight loss, ketosis/DKA, rapid insulin requirement, phenotype]. Autoantibodies: [ordered / pending / results]. C-peptide: [not yet ordered / planned timing / result]. (Do not draw C-peptide within 2 weeks of hyperglycemic crisis.)

DKA/HHS Status: [not present / suspected / confirmed / mixed] (Do not infer; document explicit criteria.)

• Hyperglycemia: Glucose [value] at [time]
• Ketosis: β-hydroxybutyrate [value] or urine ketones [result] at [time]
• Metabolic acidosis: pH [value], HCO3 [value], AG [value] at [time]
• Severity (if DKA): [mild / moderate / severe] based on [pH, bicarbonate, mental status findings]
• If HHS considered: Glucose [value], effective osmolality [value], ketosis [status], acidosis [status]

Differential considerations: [Starvation ketosis / alcoholic ketoacidosis / euglycemic DKA / other with brief reasoning] (Include only if diagnostic uncertainty exists.)

Assessment and Plan

(Problem-oriented format; highest acuity first. Omit sections that do not apply; do not leave empty headings.)

Hyperglycemic Crisis Management

(Include only if DKA or HHS is suspected or confirmed.)

Assessment: [DKA/HHS severity], [key criteria values], [suspected precipitant], [treatment phase: initial resuscitation / ongoing treatment / transition planning].

• Protocol: [Institutional protocol name]
• Fluids: [Type, bolus volumes given, current rate, dextrose addition plan]
• Insulin: [IV infusion rate] or [SQ rapid-acting per protocol for mild cases] (Write out "units"; never abbreviate as "U".)
• Potassium/Electrolytes: [Replacement plan, monitoring thresholds, phosphate/magnesium strategy]
• Monitoring: [Glucose check frequency, BMP/VBG/βHB frequency, neuro checks if severe]
• Transition plan: [Basal insulin type, dose, timing—administer at least 2 hours before stopping IV insulin], [total daily dose calculation method], [transition criteria]
• Resolution criteria: [Anion gap, bicarbonate, pH, and clinical thresholds to document before stating resolved]

New-Onset Diabetes, Likely Type 1

Assessment: [New diagnosis with supporting evidence], [classification status: confirmed vs pending], [immediate insulin requirement]. (Label uncertainty clearly with plan to confirm.)

• Consults: [Endocrinology consult status]
• Testing: [Autoantibodies ordered], [A1C if not obtained], [C-peptide timing plan]
• Glycemic targets: [Inpatient target range per protocol]

Inpatient Insulin Regimen

Assessment: [Nutritional status: NPO / poor intake / eating reliably], [glucose trends], [hypoglycemia risk factors].

• Basal insulin: [Type], [dose in units], [timing] (Do not hold basal insulin in type 1 diabetes.)
• Prandial insulin: [Fixed dose or carb-counting], [dose or ratio], [timing]
• Correction insulin: [Correction factor], [target range], [frequency]
• Bridging rationale: [If correction-only temporarily, document justification and duration]
• Hypoglycemia orders: [Oral glucose, IV dextrose, glucagon formulation and route]
• Hold parameters: [Specify parameters; explicitly note basal insulin should not be held in T1D]

Electrolyte and Fluid Management

(Include if abnormalities present.)

Assessment: [Abnormalities and relationship to DKA/treatment].

• Replacement plan: [Potassium, phosphate, magnesium, sodium considerations]
• Monitoring schedule: [Lab intervals and clinical checks]

Concurrent Illness / Trigger Evaluation

(Include if infection or other precipitant suspected.)

Assessment: [Suspected precipitant].

• Workup status: [Tests ordered, pending results, initial findings]
• Treatment: [Empiric therapy if indicated, source control]

Diabetes Education

Baseline Assessment: [Prior knowledge], [learning barriers], [interpreter needs], [caregiver availability].

Survival Skills Checklist: (Mark each: done / in progress / planned / deferred with reason.)

• [Understanding diagnosis and when to seek urgent care]
• [Glucose monitoring technique and frequency]
• [Insulin administration: injection technique, site rotation, storage]
• [Hypoglycemia recognition and treatment; glucagon training]
• [Hyperglycemia and ketone monitoring: when to check, actions to take]
• [Sick-day rules: fluids, continue insulin, monitoring frequency, thresholds to call/return]
• [Basic nutrition and carbohydrate concepts]
• [Sharps disposal]
• [Teach-back/return demonstration completed]

Education Plan: [Disciplines involved], [target completion date]

Supplies and Access

• Insulins and delivery devices: [in hand / prescribed / pending authorization]
• Glucose monitoring: [Meter, strips, lancets and/or CGM; include backup meter if CGM planned]
• Ketone testing supplies: [Blood βHB meter/strips or urine ketone strips]
• Glucagon: [Formulation], [status]
• Backup plans: [Injection supplies if pump planned; meter if CGM]
• Access support: [Case management/social work, insurance authorization, affordability interventions]

Discharge Planning and Follow-up

• Discharge destination: [Home / facility], [caregiver readiness]
• Follow-up appointments: Endocrinology [timeframe], Primary care [timeframe], Diabetes educator [timeframe], Dietitian [timeframe] (Schedule before discharge when possible.)
• Pending results for outpatient follow-up: [Autoantibodies, cultures, other]
• Return precautions: [Vomiting, elevated ketones, rapid breathing, confusion, persistent hyperglycemia, inability to keep fluids down]

Consults and Care Coordination

• Endocrinology: [Status and key recommendations]
• Diabetes education: [Status]
• Nutrition: [Status]
• Social work/case management: [Status, insurance/pharmacy coordination]
• [Other consults as applicable]

Level of Care Justification

[Medical necessity for inpatient admission: severity, IV insulin needs, monitoring requirements, comorbid risks]. [Criteria for level of care change or discharge].

Meta-Instructions

(For missing critical values—weight, ketones, pH, bicarbonate, potassium—require explicit status: known value, pending, or not obtained with reason. Prefer "not obtained (reason)" over "N/A.")

(Do not infer DKA/HHS presence, absence, severity, or resolution; require explicit criteria with values and timestamps.)

(Limited inference acceptable for "likely type 1 diabetes" when supporting features are documented and classification confirmation plan is stated.)

(Omit non-applicable sections; do not include empty headings.)

(Avoid error-prone abbreviations; never write "U" for units in insulin documentation.)

(This template is designed for adult patients. Pediatric patients require additional considerations including guardian documentation, weight-based dosing, and cerebral edema monitoring.)