Institution name

Institution Name and Address:
DIABETES MEDICAL MANAGEMENT PLAN
CONVENTIONAL THERAPY or TYPE 2
Patient Label or MRN, Acct#, Patient name, DOB, Date of Service
Part 2: Virginia Diabetes Medical Management Plan (DMMP)
To be completed by physician/provider.
Notice to Parents: Medication(s) MUST be brought to school by the PARENT/GUARDIAN in a container that is appropriately labeled
by the pharmacy or physician/practitioner.
In order for schools to safely administer medication during school hours, the following guidelines should be observed:
 A new copy of the DMMP must be completed at the beginning of each school year. This form, an Authorization for Medication Administration form, or MD prescription must be received in order to change diabetes care at school during the school year. Student Name (Last, First, MI)
Student’s Diagnosis: DIABETES:
Type 2 Today’s Date
MONITORING
BLOOD GLUCOSE (BG)
For symptoms of hypo/hyperglycemia & MONITORING with meter, lancets,
To be performed by school personnel Student is independent Additional BG monitoring may be performed at CONTINUOUS GLUCOSE
Always confirm CGM results with finger stick MONITORING (CGM)
check before taking action on sensor blood glucose level. If student has symptoms or signs of hypoglycemia, check finger stick blood Brand/Model:

Anytime the BG > mg/dL or when student complains of nausea, vomiting,
URINE KETONE TESTING
abdominal pain. See page 3 for further instructions under hyperglycemia BLOOD KETONE TESTING
NAME OF MEDICATION
DOSE/ROUTE
Immediately for severe hypoglycemia: unconscious, semi-conscious (unable to GLUCAGON - INJECTABLE
control his/her airway or unable to swallow), or seizing ORAL MEDICATIONS
POSSIBLE SIDE
TREATMENT SIDE
Physician/Provider Signature: Provider Printed Name: 2011-2012
SCHOOL YEAR
Emergency # ___________
Institution Name and Address:
DIABETES MEDICAL MANAGEMENT PLAN
Patient Label or MRN, Acct#, Patient name, DOB, Date of Service CONVENTIONAL THERAPY or TYPE 2
SCHOOL YEAR 2011-2012 DIABETES SCHOOL CARE PLAN Student: _______________
CONVENTIONAL THERAPY OR TYPE 2 DIABETES
Effective date: __________
Student can administer insulin if supervised Insulin to be given during school hours: Student can administer his/her own insulin Student can not administer insulin Insulin Types:
Meal Plan:
Rapid-acting Insulin Type: ®
according to the following distribution: Short-acting Insulin Type: Regular
Intermediate-acting Insulin Type: NPH
may mix with rapid or short-acting insulin ® units at am or pm
Insulin:CHO Ratio: 1 unit for every grams of CHO decrease by 1 unit if pre-lunch reading is less than 80 mg/dL or if (all doses to be administered subcutaneously) Pre-breakfast dose: Regular units Humalog® or Novolog® or Apidra® units NPH units Humalog® or Novolog® or Apidra® units NPH units Pre-dinner dose: Regular units Humalog® or Novolog® or Apidra® units NPH units Sliding scale to be administered at (times)
Insulin Sensitivity (Correction Factor) to be
administered at (times)
• the predicted drop in blood glucose concentration after administration of 1 unit of regular or rapid-acting insulin ____________________ give _______________________ • usually expressed as “1 unit for every ____mg/dl blood glucose is ____________________ give _______________________ ____________________ give _______________________ • If uneven, then round to the nearest half or whole unit (May use
____________________ give _______________________ clinical discretion; if physical activity follows meal, then may round down) ____________________ give _______________________ ____________________ give _______________________ • Children using NPH insulin usually require snacks without additional insulin coverage (please, adhere to CHO amounts ordered above). • Scheduled snacks may be required prior to or after exercise in order to prevent hypoglycemia. Insulin is not administered with these snacks. • Foods may be eaten at unscheduled times. Insulin may be ordered for these snacks in order to prevent post-meal hyperglycemia (see above). • Snack time insulin = # carbohydrates consumed/CHO Ratio. • Never provide insulin coverage for carbohydrate/glucose being used to treat hypoglycemia.
Exercise and Sports

• In general, there are no restrictions on activity unless specified. • A student should not exercise if his/her blood glucose is <100 mg/dL or > 300 mg/dL and ketones are positive. • A source of fast-acting glucose & glucagon (if ordered) should be available in case of hypoglycemia. Physician/Provider Signature: Provider Printed Name: 2011-2012
SCHOOL YEAR
Emergency # ___________
Institution Name and Address:
DIABETES MEDICAL MANAGEMENT PLAN
CONVENTIONAL THERAPY or TYPE 2
Patient Label or MRN, Acct#, Patient name, DOB, Date of Service SCHOOL YEAR 2011-2012 DIABETES SCHOOL CARE PLAN Student: _______________
Effective date: _________________
Hypoglycemia (Low Blood Glucose)
Hypoglycemia is defined as a blood glucose < _____ mg/dL
Signs of hypoglycemia:
suspected, check the blood glucose level. Severe Hypoglycemia: If student unconscious, semi-conscious (unable to control
his/her airway or unable to swallow), or seizing, administer glucagon.
• Place student in the “recovery position.” • If glucagon is administered, call 911 for emergency assistance, and call Parents/Legal Guardian. Mild or Moderate Hypoglycemia: If conscious & able to swallow, immediately give 15
gram fast-acting glucose:
Hypoglycemia
Management
(Low Blood Glucose)
Repeat BG check in 15 minutes
• If BG still low, then re-treat with 15 gram CHO • If BG in acceptable range and at lunch or snack time, let student eat and cover CHO per orders • If BG in acceptable range and not lunch or snack time, provide student slowly-released CHO snack (3-4 peanut butter or cheese crackers or ½ sandwich) If unable to raise the BG > 70 mg/dL despite fast-acting glucose sources, call _____________

Hyperglycemia (High Blood Glucose)
Signs of hyperglycemia:
• If hyperglycemia is suspected, check the blood glucose level. If BG > 300 mg/dL, or when child complains of nausea, vomiting, and/or abdominal
pain, ask the student to check his/her urine for ketones
• If urine ketones are trace or negative (blood ketones 0 - 1.0 mmol/L), give 8-16 ounces of sugar- Hyperglycemia
free fluid (water), return to classroom. • If correction insulin has not been administered within 3 hours, provide correction insulin according Management
to student’s Correction Factor and Target pre-meal BG • Recheck BG and ketones 2 hours after administering insulin (High Blood Glucose)
• If urine ketones are moderate/large (blood ketones > 1.0 mmol/L), give 8-16 ounces of sugar-free fluid (water) and call ____________ for instructions concerning insulin administration.
• Recheck BG and ketones 2 hours after administering insulin My signature below provides authorization for the above written orders. I/We understand that all treatments and procedures may be performed by the school nurse, the student and / or trained unlicensed designated school personnel under the training and supervision provided by the school nurse (or by EMS in the event of loss of consciousness or seizure) in accordance with state laws & regulations. I also give permission for the school to contact the health care provider regarding these orders and administration of these medications. Physician/Provider Provider Printed Name:

Source: http://www.pcva.us/health-services/wp-content/files/sites/38/2013/04/DiabetesMedicalMangement.pdf