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Acceptable Documentation Sources Medication reconciliation list showing insulin as an active current medication Provider note explicitly stating patient is on long-term insulin therapy or insulin-controlled Type 2 diabetes Prescription record for insulin within the encounter date or active medication review Problem list entry indicating insulin-dependent or insulin-controlled diabetes What Documentation Is Insufficient A history of insulin use without confirmation it is ongoing at this encounter A notation that insulin was administered during the encounter without evidence of an ongoing regimen Discharge summary from a prior hospitalization only, with no current medication confirmation Practices that use digital intake forms can embed medication status prompts that capture insulin use at every visit check-in, creating a structured data point in the record without requiring the provider to manually note it in the encounter documentation