Healthcare Diabetes Protocol

HEALTHCARE DIABETES PROTOCOL

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical & Diabetes History

Diabetes Type: Type 1 Type 2 Gestational Other:

Diagnosis Date:    Last HbA1c:    Target HbA1c:

Monitoring & Devices

Glucometer testing frequency:

Uses Continuous Glucose Monitor (CGM): Yes No

Medication Regimen & Orders

Hypoglycemia Protocol

Glucagon authorized for use by caregiver or healthcare staff: Yes No    If yes, dose:

Hyperglycemia / DKA Protocol

Sick-Day Management

Patient Responsibilities & Acknowledgements

By signing below, the patient (or legal guardian) acknowledges the following:

Patient acknowledges the right to revoke consent at any time. Revocation must be submitted in writing to the ordering provider or clinic. Patient understands that revocation does not affect actions taken in reliance on this protocol prior to receipt of revocation.

Authorization & Orders

This protocol constitutes medical orders authorized by the ordering provider below. Delegated nursing staff and other authorized personnel are permitted to implement orders within the scope described. Any deviation required for emergent clinical judgment should be documented in the medical record and communicated to the ordering provider as soon as practical.

Date of Order:

Privacy & HIPAA Acknowledgement

I acknowledge that my health information will be used and disclosed as necessary to implement this protocol. I have been offered a copy of the clinic's privacy practices.

I acknowledge receipt of privacy practices and authorize release of necessary health information to implement this diabetes protocol.

Duration of Authorization

This authorization is effective beginning:    Expires on:

The ordering provider may renew or modify this protocol in writing. If no expiration date is provided, the protocol will remain in effect until revoked in writing by the patient or legal representative, or until superseded by a new order.

Limitations, Liability, and Emergency Care

The patient understands that while this protocol authorizes specific orders and delegated care, medical judgment by treating clinicians may necessitate deviations to ensure patient safety. The facility and ordering provider are not liable for harm resulting from adherence to emergent best clinical judgment when documentation is made in the medical record. In the event of life-threatening emergency (suspected DKA, seizures, loss of consciousness, respiratory compromise), emergency medical services will be contacted immediately.

Patient Consent

I, the undersigned, have read and discussed the diabetes management plan and the orders contained within this protocol. I understand the risks and benefits of the prescribed treatment, the hypoglycemia and hyperglycemia actions, and the patient responsibilities. I consent to the implementation of this protocol by the ordering provider and authorized staff.

Sign Now