APPENDIX #1: SAMPLE Diabetes Medical Management Plan (DMMP)
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1 APPENDIX #1: SAMPLE Diabetes Medical Management Plan (DMMP) Date of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant school staff, and copies should be kept in a place that is easily accessed by the school nurse (RN), Diabetes Trained School Personnel (DTP) and other authorized personnel. Effective Date: Student s Name: Date of Birth: Grade: Physical Condition: c Diabetes type 1 c Diabetes type 2 Contact Information Date of Diabetes Diagnosis: Homeroom Teacher: Mother/Guardian: Address: Father/Guardian: Student s Doctor/Health Care Provider: Telephone: Emergency Number: Other Emergency Contact: Relationship: Telephone: Home Work Cell Notify parents/guardian or emergency contact in the following situations: 80
2 Blood Glucose Monitoring Target range for blood glucose is c c c Other Usual times to check blood glucose Times to do extra blood glucose checks (check all that apply): c before exercise c after exercise c when student exhibits symptoms of hyperglycemia c when student exhibits symptoms of hypoglycemia c other (explain): Can student perform own blood glucose checks? c Yes c No Exceptions: Type of blood glucose meter student uses: Insulin Usual Lunchtime Dose Base dose of Humalog/Novolog/Regular insulin at lunch (circle type of rapid-/short-acting insulin used) is units or does flexible dosing using units/ grams carbohydrate. Use of other insulin at lunch (circle type of insulin used): intermediate/nph/lente units or basal/lantus/ultralente units. Insulin Correction Doses Sliding Scale Method Correction Factor Method Correct blood glucose greater than mg/dl Target blood sugar for correction Correction factor 81
3 APPENDIX #1: SAMPLE Diabetes Medical Management Plan (DMMP) Date of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant school staff, and copies should be kept in a place that is easily accessed by the school nurse (RN), Diabetes Trained School Personnel (DTP) and other authorized personnel. Effective Date: Student s Name: Date of Birth: Grade: Physical Condition: c Diabetes type 1 c Diabetes type 2 Contact Information Date of Diabetes Diagnosis: Homeroom Teacher: Mother/Guardian: Address: Father/Guardian: Student s Doctor/Health Care Provider: Telephone: Emergency Number: Other Emergency Contact: Relationship: Telephone: Home Work Cell Notify parents/guardian or emergency contact in the following situations: 80
4 Blood Glucose Monitoring Target range for blood glucose is c c c Other Usual times to check blood glucose Times to do extra blood glucose checks (check all that apply): c before exercise c after exercise c when student exhibits symptoms of hyperglycemia c when student exhibits symptoms of hypoglycemia c other (explain): Can student perform own blood glucose checks? c Yes c No Exceptions: Type of blood glucose meter student uses: Insulin Usual Lunchtime Dose Base dose of Humalog/Novolog/Regular insulin at lunch (circle type of rapid-/short-acting insulin used) is units or does flexible dosing using units/ grams carbohydrate. Use of other insulin at lunch (circle type of insulin used): intermediate/nph/lente units or basal/lantus/ultralente units. Insulin Correction Doses Sliding Scale Method Correction Factor Method Correct blood glucose greater than mg/dl Target blood sugar for correction Correction factor 81
5 Can student give own injections? c Yes c No Can student determine correct amount of insulin? c Yes c No Can student draw correct dose of insulin? c Yes c No For Students with Insulin Pumps Type of pump: Basal rates: 12 am to to to Type of insulin in pump: Type of infusion set: Insulin/carbohydrate ratio: Correction factor: Student Pump Abilities/Skills: Needs Assistance Count carbohydrates c Yes c No Bolus correct amount for carbohydrates consumed c Yes c No Calculate and administer corrective bolus c Yes c No Calculate and set basal profiles c Yes c No Calculate and set temporary basal rate c Yes c No Disconnect pump c Yes c No Reconnect pump at infusion set c Yes c No Prepare reservoir and tubing c Yes c No Insert infusion set c Yes c No Troubleshoot alarms and malfunctions c Yes c No For Students Taking Oral Diabetes Medications Type of medication: Timing: Other medications: Timing: Meals and Snacks Eaten at School Is student independent in carbohydrate calculations and management? c Yes c No Meal/Snack Time Food content/amount Breakfast Mid-morning snack Lunch 82
Lander County School District
Lander County School District of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant
9-A. Diabetes Medical Management Plan
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Diabetes Medical Management Plan
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Diabetes Medical Management Plan
MADISON CONSOLIDATED SCHOOLS Diabetes Medical Management Plan Date of Plan: Effective Dates : The student s personal health care team and parents/guardian should complete this plan. It should be reviewed
Diabetes Medical Management Plan
of Plan: Diabetes Medical Management Plan These orders remain in effect during the school day, school sponsored activities, and school sponsored overnight trips. This plan should be completed by the student
Diabetes Medical Management Plan
of Plan: Diabetes Medical Management Plan (Adapted for JHU/CTY Summer Programs) This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with
Diabetes Medical Management Plan
Date of Plan: Diabetes Medical Management Plan Effective Dates: This plan should be completed by the student's personal health care team and parents/guardian. It should be reviewed with relevant school
Diabetes Medical Management Plan
Date of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies
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Diabetes Medical Management Plan
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VICTORIA INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan
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