Diabetic Medical Management Form

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SYRACUSE CITY SCHOOL DISTRICT
Health Services
725 Harrison Street• Syracuse, NY 13210
Phone 315•435•4145• Fax 315•435•4859
Sharon L. Contreras, Ph.D.
Superintendent of Schools
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: ___________________________ Date of Diabetes Diagnosis: _______________
Grade: ________________________________ Homeroom Teacher: _____________________
Physical Condition: □ Diabetes type 1
□ Diabetes type 2
Contact Information
Mother/Guardian: ______________________________________________________________
Address: _____________________________________________________________________
_____________________________________________________________________________
Telephone: Home: _________________Work: _________________Cell: _________________
Father /Guardian: ______________________________________________________________
Address: _____________________________________________________________________
_____________________________________________________________________________
Telephone: Home: _________________Work: _________________Cell: _________________
Student’s Doctor/Health Care Provider:
Name: ______________________________________________________________________
Address: _____________________________________________________________________
Telephone: _____________________________Emergency Number: _____________________
Other Emergency Contact:
Name: _______________________________________________________________________
Relationship: _________________________________________________________________
Telephone: Home: __________________Work: _________________ Cell: ________________
Notify parents/guardian or emergency contact in the following situations: _________________
_____________________________________________________________________________
_____________________________________________________________________________
Page 1
Blood Glucose Monitoring
Target range for blood glucose is: □ 70-150 □ 70-180
□ other _________________
Usual times to check blood glucose _______________________________________________
Times to do extra blood glucose checks (check all that apply):
□ before exercise
□ after exercise
□ when student exhibits symptoms of hyperglycemia
□ when student exhibits symptoms of hypoglycemia
□ other (explain): _________________________________________________________
Can student perform own blood glucose checks? □ Yes
□ 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
________units if blood glucose is _______ to _______mg/dl
________units if blood glucose is _______ to _______mg/dl
________units if blood glucose is _______ to _______mg/dl
________units if blood glucose is _______ to _______mg/dl
________units if blood glucose is _______ to _______mg/dl
Correction Factor Method
Correct blood glucose greater than _______ mg/dl
Target blood sugar for correction ________
Page 2
Correction factor: __________
Can student give own injections?
Can student determine correct amount of insulin?
Can student draw correct dose of insulin?
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
For Students with Insulin Pumps
Type of pump: __________________________ Basal rates: ______ 12am to ______
______ _____ to _____
______ _____ to _____
______ _____ to ______
______ _____ to ______
Type of insulin pump: ________________________________________________________
Type of infusion set: ________________________________________________________
Insulin/carbohydrate ratio: _________________Correction Factor: ____________________
Student Pump Abilities/Skills:
Count carbohydrates
Needs Assistance
□ Yes
□ No
Bolus correct amount for carbohydrates consumed
□ Yes
□ No
Calculate and administer corrective bolus
□ Yes
□ No
Calculate and set basal profiles
□ Yes
□ No
Calculate and set temporary basal rate
□ Yes
□ No
Disconnect pump
□ Yes
□ No
Reconnect pump at infusion set
□ Yes
□ No
Prepare reservoir and tubing
□ Yes
□ No
Insert infusion set
□ Yes
□ No
Troubleshoot alarms and malfunctions
□ Yes
□ No
For Students Taking Oral Diabetes Medications
Type of medication: ___________________________ Timing: ____________________
Other medication: ____________________________ Timing: ____________________
Meals and Snacks Eaten at School
Is student independent in carbohydrate calculations and management? □ Yes □ No
Meal/Snack
Time
Food content/amount
Breakfast
________________
_____________________________
Mid-morning snack
________________
_____________________________
Lunch
________________
____________________________
Page 3
Meal/Snack
Mid-afternoon snack
Dinner
Time
________________
________________
Food content/amount
______________________________
______________________________
Snack before exercise?
□ Yes
□ No
Snack after exercise?
□ Yes
□ No
Other times to give snacks and content/amount: ___________________________________
Preferred snack foods: ________________________________________________________
Foods to avoid, if any: ________________________________________________________
Instructions for when food is provided to the class (e.g. as part of a class party of food
sampling event): ____________________________________________________________
__________________________________________________________________________
Exercise and Sports
A fast-acting carbohydrate such as ______________________________________________
should be available at the site of exercise or sports.
Restrictions on activity, if any: ________________________________________________
Student should not exercise if blood glucose level is below _______mg/dl or above ______ mg/dl
or if moderate to large urine ketones are present.
Hypoglycemia (Low Blood Sugar)
Usual symptoms of hypoglycemia: ______________________________________________
__________________________________________________________________________
Treatment of hypoglycemia: ___________________________________________________
__________________________________________________________________________
Glucagon should be given if the student is unconscious, having seizure (convulsion) or unable
to swallow.
Route ______, Dosage_____, site for glucagon injection: ____ arm,____ thigh, ____ other.
If glucagon is required, administer it promptly. Then follow district policy for medical care.
Hyperglycemia (High Blood Sugar)
Usual symptoms of hyperglycemia: _____________________________________________
__________________________________________________________________________
Treatment of hyperglycemia: __________________________________________________
__________________________________________________________________________
Urine should be checked for ketones when blood glucose levels are above ______mg/dl.
Treatment of ketones: _____________________________________________________
________________________________________________________________________
Page 4
Supplies to be Kept at School
_________ Blood glucose meter, blood glucose test strips, batteries for meter
_________ Lancet device, lancets, gloves, etc.
_________ Urine ketone strips
_________Insulin pump and supplies
_________ Insulin pen, pen needles, insulin cartridges
_________ Fast-acting source of glucose
_________ Carbohydrate containing snack
_________ Glucagon emergency kit
Signatures
This Diabetes Medical Management Plan has been approved by:
__________________________________________
Student’s Physician/Health Care Provider
_________________________
Date
I give permission to the school nurse (RN), Diabetes-Trained School Personnel (DTP), and
other designated staff members of _____________________________________ School
to perform and carry out the diabetes care tasks as outlined by ________________________’s
Diabetes Medical Management Plan. I also consent to the release of the information contained
in the is Diabetes Medical Management Plan to all staff members and other adults who have
custodial care of my child and who may need to know this information to maintain my child’s
health and safety.
Acknowledged and received by:
__________________________________________
Student’s Parent/Guardian
__________________________
Date
__________________________________________
Student’s Parent/Guardian
__________________________
Date
*From NYSDOD Publication: Children with Diabetes: a resource guide for families and schools.
Page 5
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