Sample Diabetes Medical Management Plan 508

Diabetes Medical Management Plan (DMMP)
This plan should be completed by the students personal diabetes health care team,
including the parents/guardian. It should be reviewed with relevant school staff and
copies should be kept in a place that can be accessed easily by the school nurse, trained
diabetes personnel, and other authorized personnel.
Date of Plan:____________ This plan is valid for the current school year:______ - _____
Students Name:_ ______________________________ Date of Birth:_________________
Date of Diabetes Diagnosis:___________ otype 1
otype 2 oOther__________
Grade:__________________ Homeroom Teacher:________________________________

School Nurse: ____________________________ Phone:___________________________
CONTACT INFORMATION
Mother/Guardian:__________________________________________________________
Address:_ ________________________________________________________________
Telephone: Home_ _____________ Work_ ______________ Cell: ___________________
Email Address:_ ___________________________________________________________
Father/Guardian:___________________________________________________________
Address:_ ________________________________________________________________
Telephone: Home_ _____________ Work ______________ Cell:____________________
Email Address:_ ___________________________________________________________
Students Physician/Health Care Provider:_______________________________________
Address:_ ________________________________________________________________
Telephone:________________________________________________________________
Email Address:_ __________________ Emergency Number:_ _______________________
Other Emergency Contacts:
Name:_________________________ Relationship:_______________________________
Telephone: Home_ _____________ Work_______________ Cell:____________________
Helping the Student with Diabetes Succeed 99
Tools
School:_ ________________________ School Phone Number:_ _____________________
Diabetes Medical Management Plan (DMMP) Page 2
Checking Blood Glucose

Target range of blood glucose: o70130 mg/dL
o70180 mg/dL
oOther:_______________________________________________________________
Check blood glucose level: oBefore lunch o_____ Hours after lunch
o2 hours after a correction dose oMid-morning oBefore PE oAfter PE
oBefore dismissal oOther:_
oAs needed for signs/symptoms of low or high blood glucose
oAs needed for signs/symptoms of illness
Preferred site of testing: oFingertip oForearm oThigh oOther:_
Brand/Model of blood glucose meter:__________________________________________
Note: The fingertip should always be used to check blood glucose level if hypoglycemia is suspected.
Students self-care blood glucose checking skills:
oIndependently checks own blood glucose

oMay check blood glucose with supervision
oRequires school nurse or trained diabetes personnel to check blood glucose
Continuous Glucose Monitor (CGM): oYes
oNo
Brand/Model:_ __________________________ Alarms set for: o(low) and o(high)

Note: Confirm CGM results with blood glucose meter check before taking action on sensor blood
glucose level. If student has symptoms or signs of hypoglycemia, check fingertip blood glucose level
regardless of CGM.
HYPOGLYCEMIA TREATMENT
Students usual symptoms of hypoglycemia (list below):
________________________________________________________________________
________________________________________________________________________
If exhibiting symptoms of hypoglycemia, OR if blood glucose level is less than
_______mg/dL, give a quick-acting glucose product equal to _______ grams of
carbohydrate.
Recheck blood glucose in 1015 minutes and repeat treatment if blood glucose level is
less than _______ mg/dL.
Additional treatment:_ ______________________________________________________
100 www.YourDiabetesInfo.org
Diabetes Medical Management Plan (DMMP) Page 3

HYPOglYCEMIA TREATMENT (Continued)
Follow physical activity and sports orders (see page 7).

If the student is unable to eat or drink, is unconscious or unresponsive, or is having
seizure activity or convulsions (jerking movements), give:
Glucagon: o1 mg

o1/2 mg Route: oSC oIM

Site for glucagon injection: oarm othigh oOther:_____________________
Call 911 (Emergency Medical Services) and the students parents/guardian.

Contact students health care provider.
HYPERGLYCEMIA TREATMENT
_______________________________________________________________________
_______________________________________________________________________
Check oUrine oBlood for ketones every _____hours when blood glucose levels
are above _____mg/dL.
For blood glucose greater than _____mg/dL AND at least _____hours since last insulin
dose, give correction dose of insulin (see orders below).
For insulin pump users: see additional information for student with insulin pump.
Give extra water and/or non-sugar-containing drinks (not fruit juices): _____ounces per
hour.
Additional treatment for ketones:_____________________________________________
Follow physical activity and sports orders (see page 7).
Notify parents/guardian of onset of hyperglycemia.
If the student has symptoms of a hyperglycemia emergency, including dry mouth,
extreme thirst, nausea and vomiting, severe abdominal pain, heavy breathing or
shortness of breath, chest pain, increasing sleepiness or lethargy, or depressed level
of consciousness: Call 911 (Emergency Medical Services) and the students parents/
guardian.
Contact students health care provider.
Tools
Students usual symptoms of hyperglycemia (list below):
Diabetes Medical Management Plan (DMMP) page 4
INSULIN THERAPY
Insulin delivery device:syringeinsulin pen
oinsulin pump
Type of insulin therapy at school:
oAdjustable Insulin Therapy

oFixed Insulin Therapy
oNo insulin
Adjustable Insulin Therapy
Carbohydrate Coverage/Correction Dose:

Name of insulin:_______________________________________________________
Carbohydrate Coverage:
Insulin-to-Carbohydrate Ratio:
Lunch: 1 unit of insulin per ______ grams of carbohydrate
Snack: 1 unit of insulin per ______ grams of carbohydrate
Carbohydrate Dose Calculation Example

Grams of carbohydrate in meal

Insulin-to-carbohydrate ratio
= _____ units of insulin
Correction Dose:
Blood Glucose Correction Factor/Insulin Sensitivity Factor = ______
Target blood glucose =
mg/dL
Correction Dose Calculation Example

Correction dose scale (use instead of calculation above to determine insulin correction dose):
Blood glucose _____ to _____ mg/dL
give _______units
give _______units
give _______units
give _______units

INSUlIN THERAPY (Continued)
When to give insulin:
Lunch
oCarbohydrate coverage only
oCarbohydrate coverage plus correction dose when blood glucose is greater than
_____mg/dL and ____ hours since last insulin dose.
oOther:_
oOther:________________________________________________________________
oCorrection dose only:
For blood glucose greater than _____mg/dL AND at least _____ hours since last
insulin dose.
oOther:_______________________________________________________________
Fixed Insulin Therapy
Name of insulin:_
o____ Units of insulin given pre-lunch daily

o____ Units of insulin given pre-snack daily
oOther:______________________________________________________________
Parental Authorization to Adjust Insulin Dose:
oYes No
Parents/guardian authorization should be obtained before

administering a correction dose.
oYes
No Parents/guardian are authorized to increase or decrease correction

dose scale within the following range: +/- _____ units of insulin.
oYes
No Parents/guardian are authorized to increase or decrease insulin-tocarbohydrate ratio within the following range: _____ units
per prescribed grams of carbohydrate, +/- ___ grams of carbohydrate.
oYes
No Parents/guardian are authorized to increase or decrease fixed insulin

dose within the following range: +/- _____ units of insulin.
Tools
Snack
oNo coverage for snack
oCarbohydrate coverage only
oCarbohydrate coverage plus correction dose when blood glucose is greater than
_____mg/dL and ____ hours since last insulin dose.

INSUlIN THERAPY (Continued)
Students self-care insulin administration skills:
oYes oNo
oYes oNo
oYes oNo

Independently calculates and gives own injections

May calculate/give own injections with supervision
Requires school nurse or trained diabetes personnel to calculate/give
injections
ADDITIONAL INFORMATION FOR STUDENT WITH INSULIN PUMP

Brand/Model of pump: _ Type of insulin in pump: _______________
Basal rates during school:____________________________________________________
Type of infusion set:________________________________________________________
oFor blood glucose greater than _______ mg/dL that has not decreased within
_______ hours after correction, consider pump failure or infusion site failure. Notify
parents/guardian.
oFor infusion site failure: Insert new infusion set and/or replace reservoir.
oFor suspected pump failure: suspend or remove pump and give insulin by syringe or
pen.
Physical Activity
May disconnect from pump for sports activities oYes No

Set a temporary basal rate oYes oNo _____% temporary basal for _____ hours
Suspend pump useYes oNo
Students self-care pump skills:
Independent?
Count carbohydrates
oYes
oYes
oYes
oYes
oYes
oYes
oYes
oYes
oYes
oYes
oYes
Bolus correct amount for carbohydrates consumed

Calculate and administer correction bolus
Calculate and set basal profiles
Troubleshoot alarms and malfunctions
Calculate and set temporary basal rate

Change batteries
Disconnect pump
Reconnect pump to infusion set
Prepare reservoir and tubing
Insert infusion set
oNo
oNo
oNo
oNo
oNo
oNo
oNo
oNo
oNo
oNo
oNo
OTHER DIABETES MEDICATIONS

Name: _______________________ Dose: __________ Route:
_____ Times given: ____
Name: _______________________ Dose: __________ Route: _____ Times given: ____
MEAL PLAN
Meal/Snack
Time
Carbohydrate Content (grams)
Breakfast
_________________
Mid-morning snack _________________
Lunch
_________________
Mid-afternoon snack _________________
________ to_________
________ to_________
________ to_________
________ to_________
Instructions for when food is provided to the class (e.g., as part of a class party or food
sampling event):_
Special event/party food permitted: Parents/guardian discretion

Student discretion
Students self-care nutrition skills:
oYesNo
Independently counts carbohydrates

oYes
No May count carbohydrates with supervision
oYes
No Requires school nurse/trained diabetes personnel to count

carbohydrates
PHYSICAL ACTIVITY AND SPORTS

A quick-acting source of glucose such as oglucose tabs and/or osugar-containing
juice must be available at the site of physical education activities and sports.
o15 grams o30 grams of carbohydrate oother___________

oevery 30 minutes during oafter vigorous physical activity
Student should eat
obefore
oother_
If most recent blood glucose is less than _______ mg/dL, student can participate in
physical activity when blood glucose is corrected and above _______ mg/dL.
Avoid physical activity when blood glucose is greater than _______ mg/dL or if urine/
blood ketones are moderate to large.
(Additional information for student on insulin pump is in the insulin section on page 6.)
Tools
Other times to give snacks and content/amount:_
DISASTER PLAN
To prepare for an unplanned disaster or emergency (72 HOURS), obtain emergency
supply kit from parent/guardian.
oContinue to follow orders contained in this DMMP.

oAdditional insulin orders as follows:________________________________________
oOther:________________________________________________________________
SIGNATURES
This Diabetes Medical Management Plan has been approved by:
Students Physician/Health Care Provider
Date
I, (parent/guardian:) __________________________ give permission to the school nurse

or another qualified health care professional or trained diabetes personnel of
(school:) ______________________________ to perform and carry out the diabetes care
tasks as outlined in (student:) __________________s Diabetes Medical Management
Plan. I also consent to the release of the information contained in this Diabetes Medical
Management Plan to all school staff members and other adults who have responsibility
for my child and who may need to know this information to maintain my childs health
and safety. I also give permission to the school nurse or another qualified health care
professional to contact my childs physician/health care provider.
________________________________________________________________________
Acknowledged and received by:
Students Parent/Guardian
Date
Students Parent/Guardian
Date
School Nurse/Other Qualified Health Care Personnel
Date

Sample Diabetes Medical Management Plan 508

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Diabetes Medical Management Plan (DMMP)

Grade:__________________ Homeroom Teacher:________________________________

School:_ ________________________ School Phone Number:_ _____________________

Diabetes Medical Management Plan (DMMP) Page 2

Checking Blood Glucose

oIndependently checks own blood glucose

Brand/Model:_ __________________________ Alarms set for: o(low) and o(high)

Diabetes Medical Management Plan (DMMP) Page 3

Follow physical activity and sports orders (see page 7).

o1/2 mg Route: oSC oIM

Call 911 (Emergency Medical Services) and the students parents/guardian.

Helping the Student with Diabetes Succeed 101

Students usual symptoms of hyperglycemia (list below):

Diabetes Medical Management Plan (DMMP) page 4

Type of insulin therapy at school:

oAdjustable Insulin Therapy

Carbohydrate Coverage/Correction Dose:

Grams of carbohydrate in meal

= _____ units of insulin

Diabetes Medical Management Plan (DMMP) page 5

o____ Units of insulin given pre-lunch daily

Parents/guardian authorization should be obtained before

No Parents/guardian are authorized to increase or decrease correction

No Parents/guardian are authorized to increase or decrease fixed insulin

Helping the Student with Diabetes Succeed 103

Diabetes Medical Management Plan (DMMP) page 6

Independently calculates and gives own injections

ADDITIONAL INFORMATION FOR STUDENT WITH INSULIN PUMP

May disconnect from pump for sports activities oYes No

Bolus correct amount for carbohydrates consumed

Troubleshoot alarms and malfunctions

Calculate and set temporary basal rate

Diabetes Medical Management Plan (DMMP) page 7

OTHER DIABETES MEDICATIONS

Carbohydrate Content (grams)

Students self-care nutrition skills:

PHYSICAL ACTIVITY AND SPORTS

o15 grams o30 grams of carbohydrate oother___________

Student should eat

Helping the Student with Diabetes Succeed 105

Other times to give snacks and content/amount:_

Diabetes Medical Management Plan (DMMP) page 8

oContinue to follow orders contained in this DMMP.

I, (parent/guardian:) __________________________ give permission to the school nurse

School Nurse/Other Qualified Health Care Personnel

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Grade: Homeroom Teacher:______________