Diabetes Care Documentation in Care Homes

Why Diabetes Documentation Matters

Approximately 25-30% of care home residents have diabetes. Effective documentation ensures continuity of care, helps prevent dangerous hypo or hyperglycaemic episodes, and provides evidence for CQC inspections. Poor diabetes documentation can lead to missed insulin doses, delayed treatment of complications, and preventable hospital admissions.

Blood Glucose Monitoring

Recording blood glucose levels accurately is fundamental to diabetes management:

Target Ranges

Document the individual's target blood glucose range as specified by their diabetes team:

• Pre-meal (fasting): Typically 4-7 mmol/L
• Post-meal (2 hours after): Typically under 8.5 mmol/L
• Older adults: May have relaxed targets (e.g., 6-10 mmol/L) to reduce hypo risk

Always check the care plan for individual targets, as these vary based on age, frailty, and type of diabetes.

Insulin Administration Documentation

Insulin documentation requires precision to prevent medication errors:

Hypoglycaemia Documentation

Hypoglycaemia (low blood glucose, typically below 4 mmol/L) is a medical emergency. Document:

• Time symptoms noticed and by whom
• Symptoms observed (confusion, sweating, tremor, pallor)
• Blood glucose reading at time of episode
• Treatment given (fast-acting glucose, amount)
• Follow-up blood glucose readings (at 15 min intervals)
• When eating resumed and what was given
• Whether GP/diabetes team was notified
• Resident's condition once stable

Hypo Treatment Protocol

Document adherence to the hypo protocol:

1. Give 15-20g fast-acting glucose (e.g., 150ml fruit juice)
2. Recheck BG after 15 minutes
3. Repeat treatment if still below 4 mmol/L
4. Once above 4 mmol/L, give longer-acting carbohydrate

Hyperglycaemia Documentation

High blood glucose (hyperglycaemia) also requires careful documentation:

• Blood glucose reading and time
• Symptoms if present (increased thirst, frequent urination, fatigue)
• Possible causes identified (missed insulin, infection, diet)
• Action taken (additional fluids, insulin as prescribed)
• When GP/diabetes team was contacted
• Follow-up readings and response to treatment

Diabetic Foot Care Documentation

Diabetic foot problems are a leading cause of amputation. Document foot checks regularly:

• Daily checks: Visual inspection for cuts, blisters, redness, swelling
• Weekly detailed check: Skin condition, nail health, sensation if trained
• Any concerns: Photographed with consent, reported to GP/podiatrist
• Podiatry appointments: Dates, findings, recommendations

Dietary Documentation

For residents with diabetes, food and fluid charts should note:

• Carbohydrate intake at each meal (where carb counting is used)
• Timing of meals relative to insulin
• Any dietary modifications (diabetic diet, texture modified)
• Snacks given, especially for hypo prevention
• Fluid intake to prevent dehydration

Annual Review Documentation

Ensure the care plan captures the resident's annual diabetes review with their GP or specialist, including:

• HbA1c results (long-term glucose control indicator)
• Any medication changes
• Eye screening results
• Kidney function tests
• Cardiovascular risk assessment
• Updated target ranges if changed

Care Plan Requirements

The diabetes care plan should clearly document:

• Type of diabetes (Type 1, Type 2, other)
• Current medication regimen with doses and timing
• Blood glucose testing frequency and target ranges
• Signs of hypo/hyperglycaemia specific to this resident
• Emergency protocols and when to call for help
• Dietary requirements and preferences
• Resident's level of involvement in self-management