The Quick Guide to Hyperglycemia SOAP Note

Hyperglycemia sits at a challenging intersection in medical documentation.

It's common enough that you see it constantly, yet serious enough that poor documentation can have real consequences—missed DKA diagnoses, inadequate discharge planning, or insurance denials for necessary medications and supplies.

I've watched providers struggle with this balance constantly.

You're dealing with patients who range from newly diagnosed diabetics in crisis to established patients with medication non-adherence to elderly patients with complex medication regimens.

Each situation requires different documentation approaches, yet insurance companies and hospital administrators expect the same level of detail regardless of context.

The documentation challenge is real: you need to capture the immediate glucose management while also addressing the underlying causes, documenting diabetes education, and justifying ongoing treatment intensity—all while seeing your next patient.

This is exactly why SOAP Notes Doctor exists—to handle the documentation complexity while you focus on clinical decision-making.

Let me walk you through what actually matters when documenting hyperglycemia.

Understanding the Documentation Stakes for Hyperglycemia

Hyperglycemia documentation carries higher stakes than many routine conditions because it sits at the convergence of multiple healthcare priorities.

Emergency departments need clear documentation distinguishing simple hyperglycemia from DKA or HHS to justify admission decisions and explain ED resource utilization.

Primary care practices face quality measure scrutiny around diabetes control rates (HbA1c less than 8% or less than 9%), making every hyperglycemia visit a potential quality score impact.

Endocrinologists require detailed documentation of previous medication trials, adherence patterns, and hypoglycemia risk before insurance will approve newer expensive agents like GLP-1 agonists or SGLT2 inhibitors.

Hospital utilization reviewers question admission necessity when glucose levels drop quickly, demanding documentation of DKA criteria or other compelling reasons for inpatient status.

Your hyperglycemia notes need to accomplish something difficult: capture clinical urgency when it exists, document appropriate outpatient management when it doesn't, and create a paper trail that justifies your clinical decisions to multiple different review processes.

The Three Types of Hyperglycemia Encounters

Not all hyperglycemia visits are the same, and your documentation should reflect these distinctions:

Acute symptomatic hyperglycemia requires urgent intervention and detailed assessment for DKA or HHS. Your documentation needs to capture severity markers and justify immediate treatment decisions.

Chronic uncontrolled diabetes needs documentation focused on barriers to control, medication adherence, diabetes self-management education, and systematic treatment intensification.

New-onset hyperglycemia requires comprehensive initial workup documentation, including type classification, complication screening, and extensive patient education.

Each scenario demands different documentation emphasis, and insurance reviewers can tell when you've used a generic template that doesn't match the clinical situation.

Let me show you how to document each type effectively.

Example 1: Symptomatic Hyperglycemia in Emergency Department

Patient: 34-year-old female with type 1 diabetes
Chief Complaint: High blood sugar, vomiting, abdominal pain
Visit: Emergency department evaluation

S – Subjective:

Patient with history of type 1 diabetes (diagnosed age 16) presents with 2 days of progressive nausea, vomiting (6-8 episodes), and diffuse abdominal pain. Reports blood glucose readings greater than 400 mg/dL at home on multiple checks over past 24 hours. Has been unable to eat or drink due to nausea. Continued taking usual insulin doses (Lantus 24 units daily, Humalog with meals) but vomited shortly after last two doses. Reports increased urination and thirst. Mild shortness of breath. Started with mild URI symptoms 4 days ago. Denies fever currently. Last HbA1c 3 months ago was 8.2%. Uses insulin pump normally but switched to injections yesterday when pump malfunctioned. Denies alcohol or drug use.

O – Objective:

Vital Signs: BP 102/64, HR 118, RR 24, Temp 98.1°F, O2 sat 98% RA, Wt 128 lbs
General: Appears ill, dry mucous membranes, mild distress from nausea
HEENT: Mucous membranes dry, no thrush
Cardiovascular: Tachycardic, regular rhythm, no murmurs
Respiratory: Tachypneic, lungs clear, no Kussmaul breathing
Abdomen: Diffusely tender without guarding or rebound, hyperactive bowel sounds
Skin: Warm, dry, poor skin turgor
Labs:

• Glucose 462 mg/dL (critical)
• pH 7.28 (low, consistent with acidosis)
• Bicarbonate 14 mEq/L (low)
• Anion gap 22 (elevated)
• Beta-hydroxybutyrate 4.8 mmol/L (markedly elevated)
• Creatinine 1.4 mg/dL (elevated from baseline 0.9)
• Potassium 5.2 mEq/L
• Urinalysis: 3+ glucose, 3+ ketones, no infection

A – Assessment:

Diabetic ketoacidosis (DKA), mild to moderate severity based on pH 7.28 and mental status. Precipitated by insulin pump malfunction and inadequate insulin administration in setting of increased insulin requirements from viral illness (recent URI). Patient meets criteria for DKA: glucose greater than 250 mg/dL, pH less than 7.30, bicarbonate less than 18, positive ketones. Volume depleted based on tachycardia, dry mucous membranes, elevated creatinine, and poor skin turgor. Requires IV insulin infusion and aggressive fluid resuscitation. Not appropriate for outpatient management given metabolic acidosis and inability to tolerate oral intake.

P – Plan:

Immediate Management:

• Admitted to ICU for DKA protocol and continuous monitoring
• IV access established, started normal saline bolus 1L over 1 hour, then 250 mL/hr
• Insulin infusion protocol initiated at 0.1 units/kg/hr (6 units/hr based on 60 kg weight)
• Continuous cardiac monitoring
• Hourly blood glucose checks, q4h electrolytes initially

DKA Protocol:

• Glucose goal 150-200 mg/dL during initial resuscitation
• When glucose less than 250, will switch to D5 1/2 NS to continue insulin infusion while avoiding hypoglycemia
• Potassium replacement when level drops below 5.0 (anticipating decrease with insulin therapy and acidosis correction)
• Continue IV insulin until anion gap closes and pH greater than 7.30, then transition to subcutaneous regimen

Precipitating Factor Management:

• Supportive care for viral illness
• Anti-emetics: ondansetron 4mg IV administered
• Diabetes educator consult for pump malfunction troubleshooting and backup planning

Transition Planning:

• Will resume home insulin regimen once tolerating oral intake and acidosis resolved
• Reviewed backup plan for insulin pump failures—always have long-acting insulin available
• Patient education on sick day management and when to seek emergency care

Follow-up: Endocrinology consult placed for inpatient management assistance and post-discharge follow-up within 1 week. Will reassess pump equipment before discharge and ensure patient has supplies and education for preventing recurrence.

---

Example 2: Uncontrolled Type 2 Diabetes in Primary Care

Patient: 56-year-old male with type 2 diabetes
Chief Complaint: Diabetes follow-up, blood sugars running high
Visit: Primary care chronic disease management

S – Subjective:

Patient presents for diabetes management. Diagnosed with type 2 diabetes 4 years ago, last HbA1c 6 months ago was 9.4%. Reports home glucose readings ranging 220-280 mg/dL fasting, higher after meals. Currently on metformin 1000mg twice daily and glipizide 10mg twice daily. States he takes medications "most days" but sometimes forgets evening doses, especially when working late. Diet inconsistent—eats fast food 3-4 times weekly, large portions at dinner. Minimal exercise, works desk job. Recently started experiencing occasional blurred vision and increased urinary frequency. Feet sometimes feel "tingly" at night. Denies chest pain, shortness of breath, or leg swelling. Concerned about starting insulin, states "I don't want to be on shots."

O – Objective:

Vital Signs: BP 142/88, HR 76, Wt 238 lbs (up 8 lbs from 6 months ago), BMI 34.2
General: Obese male, no acute distress
HEENT: Fundoscopic exam shows minimal background retinopathy
Cardiovascular: Regular rate and rhythm, no murmurs
Extremities: Peripheral pulses intact, monofilament testing shows decreased sensation bilateral feet, no wounds or ulcerations
Labs (fasting, drawn today):

• Glucose 264 mg/dL
• HbA1c 9.8% (significantly elevated, worsened from 9.4% six months ago)
• Creatinine 1.2 mg/dL, eGFR 68 (mild decline)
• Urinalysis: 2+ protein (microalbuminuria present)
• Lipids: LDL 138 mg/dL, HDL 38 mg/dL, triglycerides 246 mg/dL

A – Assessment:

Type 2 diabetes mellitus, poorly controlled with HbA1c 9.8% and worsening control trend despite current oral medication regimen. Contributing factors include medication non-adherence (missed doses), poor dietary habits, obesity, and sedentary lifestyle. Patient has developed microvascular complications: early diabetic retinopathy, peripheral neuropathy, and diabetic nephropathy (proteinuria with declining renal function). Current two-drug oral regimen insufficient for glycemic control. Patient requires treatment intensification with likely need for injectable therapy (GLP-1 agonist preferred over insulin given patient resistance and weight gain concerns). Also needs optimization of cardiovascular risk factors including hypertension and dyslipidemia.

P – Plan:

Medication Intensification: Discussed need to intensify diabetes treatment given HbA1c 9.8% and presence of complications. Patient strongly resistant to insulin. Proposed starting GLP-1 agonist (semaglutide 0.25mg weekly, titrating up) which offers glucose control plus weight loss benefit and low hypoglycemia risk. Continue metformin 1000mg BID. Discontinuing glipizide due to hypoglycemia risk, weight gain, and inadequate efficacy. Prior authorization submitted for semaglutide with documentation of failed dual oral therapy, HbA1c greater than 9%, and obesity.

Adherence Support: Addressed medication adherence challenges. Discussed using phone alarms as reminders for evening metformin dose. Emphasized importance of consistent medication use for preventing complications. Patient verbalized understanding and commitment to daily adherence.

Diabetes Education: Referred to diabetes educator for comprehensive DSME (diabetes self-management education) focused on carbohydrate awareness, portion control, and meal planning. Provided nutritional counseling on reducing fast food, choosing lower glycemic index foods, and appropriate portions.

Complication Management:

• Retinopathy: Referred to ophthalmology for dilated exam and treatment planning
• Nephropathy: Started ACE inhibitor (lisinopril 10mg daily) for renoprotection and blood pressure control given proteinuria and hypertension
• Neuropathy: Discussed foot care, daily foot inspections, appropriate footwear. Prescribed gabapentin 300mg bedtime for neuropathic pain symptoms, can titrate up if needed

Cardiovascular Risk: Initiated atorvastatin 40mg daily for LDL goal less than 70 mg/dL given diabetes plus microvascular disease (high cardiovascular risk category).

Monitoring: Patient to start checking fasting glucose daily and maintain log. Recheck HbA1c in 3 months after starting semaglutide. Follow-up appointment in 4 weeks to assess semaglutide tolerance and review glucose logs. Will assess need for additional medication adjustments based on response.

Patient Education: Explained consequences of uncontrolled diabetes including progression of current complications. Discussed realistic HbA1c goal of less than 7% and what that requires in terms of lifestyle and medication adherence. Patient expressed motivation to improve control after learning about complications. Provided written materials on diabetes management and emergency numbers.

---

Example 3: New-Onset Hyperglycemia, Initial Diagnosis

Patient: 42-year-old female
Chief Complaint: Increased thirst, frequent urination, fatigue for 3 weeks
Visit: New patient evaluation

S – Subjective:

Patient presents with 3-week history of increased thirst, drinking 8-10 glasses of water daily (previously 3-4), urinating every 1-2 hours including 4-5 times nightly. Unintentional weight loss of 12 lbs over past 6 weeks despite good appetite. Progressive fatigue making it difficult to complete usual activities. Occasional blurred vision. Denies fever, cough, dysuria, or abdominal pain. Family history significant for type 2 diabetes (mother diagnosed age 48, father age 55). No personal history of diabetes, last physical exam 2 years ago reportedly normal. Works as office manager, high-stress job. Diet includes regular sodas, processed foods. Limited exercise. No tobacco, occasional alcohol.

O – Objective:

Vital Signs: BP 128/82, HR 88, Wt 172 lbs, Ht 5'6", BMI 27.8
General: Appears fatigued but alert, dry lips
HEENT: Mucous membranes slightly dry, fundoscopic exam normal (no retinopathy)
Cardiovascular: Regular rate and rhythm
Respiratory: Clear bilaterally
Abdomen: Soft, non-tender
Extremities: No edema, peripheral pulses intact, monofilament sensation intact bilaterally
Labs (random, non-fasting):

• Random glucose 342 mg/dL (markedly elevated)
• HbA1c 10.2% (diagnostic for diabetes)
• Comprehensive metabolic panel: Normal except glucose, creatinine 0.8 (normal), electrolytes normal
• Lipid panel: Total cholesterol 224, LDL 148, HDL 42, triglycerides 198
• Urinalysis: 3+ glucose, trace ketones, no protein, no infection
• TSH: 2.1 (normal) Additional testing: GAD antibodies ordered to assess for type 1 vs type 2

A – Assessment:

New-onset diabetes mellitus, type to be determined (GAD antibodies pending but clinical picture most consistent with type 2 given age, family history, and BMI). Patient meets diagnostic criteria: symptoms of hyperglycemia plus random glucose greater than 200 mg/dL, confirmed with HbA1c 10.2%. Significantly elevated glucose and HbA1c indicate substantial insulin deficiency or resistance. Patient symptomatic with classic hyperglycemic symptoms: polyuria, polydipsia, weight loss, and fatigue. No evidence of DKA—minimal ketones, normal electrolytes, no acidosis symptoms, maintaining oral intake. Appropriate for outpatient management with aggressive initial treatment. Dyslipidemia present requiring management as part of comprehensive cardiovascular risk reduction.

P – Plan:

Diabetes Confirmation and Classification: Diagnosis of diabetes confirmed based on symptoms plus random glucose greater than 200 and HbA1c greater than 6.5%. GAD antibodies pending to differentiate type 1 vs type 2, but clinical scenario most consistent with type 2. Will adjust treatment if GAD positive.

Initial Pharmacologic Management: Given significantly elevated HbA1c (10.2%), starting combination therapy rather than metformin monotherapy:

• Metformin 500mg twice daily with meals, will increase to 1000mg BID after 1 week if tolerated (titrating to reduce GI side effects)
• Considered starting insulin given HbA1c greater than 10%, but patient maintaining weight and no signs of severe insulin deficiency. Will monitor closely and add insulin if inadequate response to oral agents
• Atorvastatin 20mg daily for dyslipidemia and cardiovascular risk reduction

Glucose Monitoring: Prescribed glucometer and testing supplies. Patient to check fasting glucose daily and 2-hour post-meal glucose after largest meal. Bring log to follow-up. Taught proper testing technique in office, patient demonstrated understanding.

Comprehensive Diabetes Education: Urgent referral to certified diabetes educator for DSME covering: disease pathophysiology, medication management, glucose monitoring, nutrition fundamentals, sick day management, hypoglycemia recognition and treatment, foot care, and when to seek emergency care. First appointment scheduled within 1 week.

Nutritional Counseling: Provided initial guidance: eliminate regular sodas and sugar-sweetened beverages, focus on balanced meals with appropriate portions, increase fiber and vegetables, reduce processed carbohydrates. Formal nutrition consultation arranged.

Complication Screening:

• Ophthalmology referral for dilated retinal exam (screening for retinopathy)
• Spot urine albumin-to-creatinine ratio ordered (screening for nephropathy)
• Foot exam performed today, patient educated on daily foot inspections and proper footwear

Follow-up: Return in 2 weeks for diabetes education follow-up, medication tolerance assessment, and glucose log review. Will check HbA1c in 3 months to assess treatment response (goal HbA1c less than 7% for newly diagnosed patient without complications). Provided 24-hour phone number for urgent questions or concerns. Reviewed hyperglycemia symptoms requiring emergency evaluation: persistent nausea/vomiting, severe abdominal pain, difficulty breathing, confusion.

Patient Education Materials: Provided written materials on diabetes basics, carbohydrate counting guide, hypoglycemia symptoms and treatment, and emergency contact information. Patient verbalized understanding of diagnosis, treatment plan, and importance of medication adherence and lifestyle modifications.

---

Essential Elements for Hyperglycemia Documentation

After reviewing thousands of hyperglycemia notes through various insurance audits and utilization reviews, these elements consistently determine whether documentation is considered adequate:

Specific Glucose Values and Timing

Never write "glucose elevated" without the actual value. Document if fasting, random, or post-prandial. Include home glucose log data when available.

Symptom Severity Assessment

Document presence or absence of classic hyperglycemic symptoms (polyuria, polydipsia, weight loss) and concerning features suggesting DKA/HHS (nausea, vomiting, abdominal pain, altered mental status, Kussmaul respirations).

DKA/HHS Evaluation When Appropriate

For glucose greater than 400 mg/dL or symptomatic patients, document assessment for ketoacidosis: mention ketones, pH/bicarb if checked, mental status, and respiratory pattern.

Medication Adherence Inquiry

Don't assume non-adherence, but do document that you asked about medication taking patterns, barriers, and understanding.

Previous Treatment Response

Reference prior HbA1c values and glucose trends. Show that current treatment decisions are based on documented treatment failures or inadequate response.

Diabetes Education Provision

Document specific topics covered or referral to diabetes educator. Insurance and quality programs want evidence of education provision.

Complication Screening Status

Document presence/absence of retinopathy, nephropathy, neuropathy, and cardiovascular disease. Note when last screened and any due screening referrals.

Hypoglycemia Risk Assessment

When intensifying treatment, document consideration of hypoglycemia risk and strategies to minimize it.

Common Documentation Pitfalls in Hyperglycemia Management

Here are the mistakes I see most frequently that lead to denied claims, failed quality measures, or utilization review challenges:

"Glucose elevated, continue current regimen" when HbA1c is greater than 9% fails to demonstrate appropriate treatment intensification and gets flagged in quality reviews.

Starting expensive medications (GLP-1 agonists, SGLT2 inhibitors) without documenting failed trials of metformin and evidence-based rationale leads to prior authorization denials.

Admitting for "hyperglycemia" with glucose 350 but no DKA criteria gets questioned by utilization review unless you document specific reasons outpatient management was inappropriate.

Discharging ED patients with glucose greater than 400 without documenting absence of DKA criteria (pH, ketones, bicarbonate) or arranging close follow-up creates liability concerns.

Generic diabetes education statements like "patient counseled on diabetes management" don't satisfy quality measure requirements—need specific topics documented.

Making Hyperglycemia Documentation More Efficient

The challenge with hyperglycemia notes is balancing completeness with efficiency, especially when you're managing multiple concurrent issues.

Here's what works:

Create structured templates that prompt you to address all necessary elements but remain flexible for individual patient circumstances.

Use specific values and comparisons: "HbA1c today 9.2%, increased from 8.4% three months ago" is far more meaningful than "diabetes uncontrolled."

Document decision-making rationale explicitly: "Starting GLP-1 agonist rather than insulin given patient resistance to injections, obesity (BMI 34), and low hypoglycemia risk with this agent class."

Reference guidelines when appropriate: "Intensifying treatment per ADA Standards of Care given HbA1c greater than 9% despite dual oral therapy."

Bundle education documentation: "Provided comprehensive diabetes education including medication administration, glucose monitoring, dietary modifications, hypoglycemia recognition and treatment, and sick day management."

Or, better yet, let SOAP Notes Doctor handle the structure while you focus on clinical details.

Record your key findings—the glucose values, symptoms, medication changes, education topics—and the system automatically formats everything properly with appropriate medical necessity language, guideline references, and quality measure documentation.

Try it at soapnotes.doctor and see how it streamlines hyperglycemia documentation.

---

Ready to simplify your hyperglycemia documentation?
Visit soapnotes.doctor and generate comprehensive diabetes notes that satisfy insurance requirements while capturing clinical complexity.