Diabetes Medical Management Plan (DMMP)

This plan should be completed by the student’s 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: _________ – ____________
Student’s Name: __________________________________ Date of Birth: __________________________________
Date of Diabetes Diagnosis: __________________________________ ☐ type 1 ☐ type 2 ☐ Other
School: __________________________________ School Phone Number: __________________________________
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: __________________________________
Student’s Physician/Health Care Provider: __________________________________
Address: __________________________________
Telephone: __________________________________
Email Address: __________________________________ Emergency Number: __________________________________

Other Emergency Contacts:
Name: __________________________________
Relationship:__________________________________
Telephone: Home __________________________________
Work __________________________________ Cell: __________________________________

Checking Blood Glucose

Target range of blood glucose: ☐ 70–130 mg/dL ☐ 70–180 mg/dL

☐ Other: ______________________________________________________________________

Check blood glucose level: ☐ Before lunch ☐ __________________________________ Hours after lunch

☐ 2 hours after a correction dose ☐ Mid-morning ☐ Before PE ☐ After PE ☐ Before dismissal
☐ Other:__________________________________
☐ As needed for signs/symptoms of low or high blood glucose
☐ As needed for signs/symptoms of illness

Preferred site of testing: ☐ Fingertip ☐ Forearm ☐ Thigh ☐ Other: __________________________________
Brand/Model of blood glucose meter:__________________________________
Note: The fingertip should always be used to check blood glucose level if hypoglycemia is suspected.

Student’s self-care blood glucose checking skills:
☐ Independently checks own blood glucose
☐ May check blood glucose with supervision
☐ Requires school nurse or trained diabetes personnel to check blood glucose

Continuous glucose Monitor (CGM): ☐ Yes ☐ No

Brand/Model: __________________________________
Alarms set for: ☐ (low) and ☐ (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

Student’s 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 10–15 minutes and repeat treatment if blood glucose level is less than ___________ mg/dL.

Additional treatment: __________________________________

Follow physical activity and sports orders.

• If the student is unable to eat or drink, is unconscious or unresponsive, or is having seizure activity or convulsions (jerking movements), give:
• Glucagon: ☐ 1 mg ☐ 1/2 mg Route: ☐ SC ☐ IM
• Site for glucagon injection: ☐ arm ☐ thigh ☐ Other: __________________________________
• Call 911 (Emergency Medical Services) and the student’s parents/guardian.
• Contact student’s health care provider.

Hyperglycemia Treatment

Student’s usual symptoms of hyperglycemia (list below):

_____________________________________________________________________________________

_____________________________________________________________________________________

Check ☐ Urine ☐ Blood 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.

• 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 student’s parents/guardian.
• Contact student’s health care provider.

INSUlIN THERAPY

Insulin delivery device: ☐ syringe ☐ insulin pen ☐ insulin pump

Type of insulin therapy at school:
☐ Adjustable Insulin Therapy
☐ Fixed Insulin Therapy
☐ No 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

• Correction Dose:
Blood Glucose Correction Factor/Insulin Sensitivity Factor = _____________
Target blood glucose = ___________ mg/dL

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

When to give insulin:

Lunch

☐ Carbohydrate coverage only

☐ Carbohydrate coverage plus correction dose when blood glucose is greater than ___________mg/dL and _________ hours since last insulin dose.

☐ Other: ________________________________________________________________________

Snack

☐ No coverage for snack

☐ Carbohydrate coverage only

☐ Carbohydrate coverage plus correction dose when blood glucose is greater than __________mg/dL and _________ hours since last insulin dose.

☐ Other: ___________________________________________________________________________

☐ Correction dose only:

For blood glucose greater than _________mg/dL AND at least _________ hours since last insulin dose.

☐ Other: ____________________________________________________________________________

Fixed Insulin Therapy

Name of insulin: __________________________________

☐ __________________________________ Units of insulin given pre-lunch daily

☐ __________________________________ Units of insulin given pre-snack daily

☐ Other: _______________________________________________________________

Parental Authorization to Adjust Insulin Dose:

☐ Yes ☐ No Parents/guardian authorization should be obtained before administering a correction dose.

☐ Yes ☐ No Parents/guardian are authorized to increase or decrease correction dose scale within the following range: +/- __________________________________ units of insulin.

☐ Yes ☐ No Parents/guardian are authorized to increase or decrease insulin-to- carbohydrate ratio within the following range: __________________________________ units per prescribed grams of carbohydrate, +/- __________________________________ grams of carbohydrate.

☐ Yes ☐ No Parents/guardian are authorized to increase or decrease fixed insulin dose within the following range: +/- __________________________________ units of insulin.

Student’s self-care insulin administration skills:

☐ Yes ☐ No – Independently calculates and gives own injections

☐ Yes ☐ No – May calculate/give own injections with supervision

☐ Yes ☐ No – 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: __________________________________

☐ For blood glucose greater than __________________________________ mg/dL that has not decreased within ___________ hours after correction, consider pump failure or infusion site failure. Notify parents/guardian.

☐ For infusion site failure: Insert new infusion set and/or replace reservoir.

☐ For suspected pump failure: suspend or remove pump and give insulin by syringe or pen.

Physical Activity

May disconnect from pump for sports activities ☐ Yes ☐ No
Set a temporary basal rate ☐ Yes ☐ No __________________________________% temporary basal for __________________________________ hours
Suspend pump use ☐ Yes ☐ No

Student’s self-care pump skills:	Independent?
Count carbohydrates	☐ Yes ☐ No
Bolus correct amount for carbohydrates consumed	☐ Yes ☐ No
Calculate and administer correction bolus	☐ Yes ☐ No
Calculate and set basal profiles	☐ Yes ☐ No
Calculate and set temporary basal rate	☐ Yes ☐ No
Change batteries	☐ Yes ☐ No
Disconnect pump	☐ Yes ☐ No
Reconnect pump to infusion set	☐ Yes ☐ No
Prepare reservoir and tubing	☐ Yes ☐ No
Insert infusion set	☐ Yes ☐ No
Troubleshoot alarms and malfunctions	☐ Yes ☐ No

Other Diabetes Medications

Name: __________________________________ Dose: ________________________ Route: __________ Times given: ________
Name: __________________________________ Dose: ________________________ Route: __________ Times given: ________

Meal Plan

Meal/Snack	Time	Carbohydrate Content (grams)
Breakfast	_________________________________	________________to____________________
Mid-morning snack	_________________________________	________________to____________________
Lunch	_________________________________	________________to____________________
Mid-afternoon snack	_________________________________	________________to____________________

Other times to give snacks and content/amount:__________________________________ 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

_____________________________________________________________________________________

Student’s self-care nutrition skills:

☐ Yes ☐ No – Independently counts carbohydrates

☐ Yes ☐ No – May count carbohydrates with supervision

☐ Yes ☐ No – Requires school nurse/trained diabetes personnel to count carbohydrates

Physical Activity and Sports

A quick-acting source of glucose such as ☐ glucose tabs and/or ☐ sugar-containing juice must be available at the site of physical education activities and sports.
Student should eat ☐ 15 grams ☐ 30 grams of carbohydrate ☐ other__________________________________

☐ before ☐ every 30 minutes during ☐ after vigorous physical activity

☐ other __________________________________________________________________________________________

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.

Disaster Plan

To prepare for an unplanned disaster or emergency (72 HOURS), obtain emergency
supply kit from parent/guardian.

☐ Continue to follow orders contained in this DMMP.

☐ Additional insulin orders as follows:

☐ Other:

Signatures

This Diabetes Medical Management Plan has been approved by:

_____________________________________________________________________________________
Student’s 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 child’s health and safety. I also give permission to the school nurse or another qualified health care professional to contact my child’s physician/health care provider.

_____________________________________________________________________________________

Acknowledged and received by:

_____________________________________________________________________________________
Student’s Parent/Guardian Date

_____________________________________________________________________________________
Student’s Parent/Guardian Date

_____________________________________________________________________________________
School Nurse/Other Qualified Health Care Personnel Date