How should an insulin pump be documented in the Medications section of a SOAP note?

How to Document Insulin Pump in SOAP Note Medications Section

Document the insulin pump by specifying: (1) the delivery method as "Insulin pump (CSII)" or specific device name, (2) the type of rapid-acting insulin analog used (e.g., insulin lispro, aspart, or glulisine), and (3) the current basal rate and insulin-to-carbohydrate ratio settings.

Essential Documentation Components

When documenting an insulin pump in the medications section of a SOAP note, include these specific elements:

Core Information to Document

• Device type: Write "Continuous Subcutaneous Insulin Infusion (CSII)" or the specific pump brand/model (e.g., "Medtronic 780G," "Omnipod 5," "Tandem t:slim X2")
• Insulin type: Only rapid-acting insulin analogs are used in pumps 1. Document the specific analog:
  • Insulin lispro (Humalog)
  • Insulin aspart (Novolog)
  • Insulin glulisine (Apidra)
• Current settings (if available from patient):
  • Total daily dose (TDD)
  • Basal rate(s) in units/hour
  • Insulin-to-carbohydrate ratio (ICR)
  • Insulin sensitivity factor (ISF) or correction factor

Example Documentation Formats

Basic format:

• "Insulin pump (CSII) with insulin lispro; basal rate 0.8 units/hr, ICR 1:10, ISF 1:50"

Detailed format for AID systems:

• "Tandem t:slim X2 with Control-IQ (hybrid closed-loop AID system); insulin aspart; automated basal delivery with target glucose 110 mg/dL"

Minimal format when settings unknown:

• "Personal insulin pump (CSII) - patient manages independently"

Critical Clinical Context

Why Specific Documentation Matters

The type of insulin matters because only rapid-acting analogs (not regular insulin or long-acting insulins) should be used in pumps 1, 2, 1. Mixtures of insulins are not evaluated and not recommended 1. This is a safety issue—documenting the wrong insulin type could indicate a dangerous medication error.

Safety Considerations to Note

When documenting pump therapy, be aware that 3:

• Pump users become relatively insulin deficient within 1 hour and absolutely deficient within 4 hours if the pump is disconnected or malfunctions
• This creates rapid risk for hyperglycemia and ketoacidosis
• If the patient cannot manage the pump independently (e.g., postoperatively, during illness), you must document transition to subcutaneous basal-bolus insulin regimen 4

When Patient Cannot Self-Manage

If documenting during hospitalization or perioperative period when the patient is not autonomous with their pump 4:

• Document: "Personal insulin pump discontinued - transitioned to subcutaneous basal-bolus regimen"
• Then list the specific basal and bolus insulin regimen being used

Additional Documentation Tips

For Automated Insulin Delivery (AID) Systems

If the patient uses a hybrid closed-loop or automated system 5, 6:

• Specify this is an AID system
• Note whether it includes integrated continuous glucose monitoring (CGM)
• Example: "Medtronic 780G AID system with Guardian 4 CGM; insulin aspart"

What NOT to Document

Avoid vague entries like:

• "Insulin pump" (without insulin type)
• "Takes insulin via pump" (lacks specificity)
• Listing long-acting insulin with pump therapy (this is incorrect—pumps use only rapid-acting insulin)

Common Pitfall

Do not assume the patient is on multiple daily injections if they mention "insulin." Always ask specifically about pump use, as pump therapy requires different perioperative and acute care management than injection therapy 3, 4, 3.