Virginia school diabetes medical management forms

Virginia School Diabetes Medical Management Forms
Student ___________________________ School ____________________ Effective Date _______________
Date of Birth ________________ Grade __________ Homeroom Teacher ____________________________
Instructions:

1. Part 1- Contact Information and Diabetes Medical History. To be completed by parent/guardian
and returned to school nurse (prior to beginning of each school year or upon diagnosis). ►Includes: Parent authorization for trained school designees to administer insulin and/or glucagon (required by Virginia Law). 2. Part 2*- Diabetes Medical Management Plan (DMMP). Student’s physician/provider to complete
Intensive Therapy or Conventional Therapy/Type 2 version of DMMP. Please note that physician authorization for treatment by trained school designees must be included in the Diabetes Medical Management Plan or a separate form must be provided. 3. Part 3*- Insulin Pump Supplement. Have the physician/provider, diabetes educator, and
parent/guardian collaborate to complete appropriate portions if your child wears an insulin pump. 4. Part 4- Permission to Self-Carry and Self-Administer Diabetes Care. To be completed by the
physician/provider, school nurse and the parent/guardian if your child is going to carry and self administer insulin and/or perform blood glucose checks in the classroom. 5. Virginia Diabetes Council School Diabetes Care Practice and Protocol provides guidelines,
accepted accommodations and references applicable to all students with diabetes. This document is available from your school nurse, the Department of Education Office of Student Services, or the Virginia Diabetes Council. *Other Diabetes Medical Management Plans may be used for Parts 2, 3 & 4 as long as all components are represented.
Return completed forms to the school nurse as quickly as possible. Thank you for your cooperation.
School nurse___________________________________ Phone______________ Date______________
Part 1: Contact Information and Diabetes Medical History
To be completed by Parent/Guardian:

Parent/Guardian #1:___________________________________________________________________
Address: ______________________________________________________________________________ Telephone-Home: _______________________Work: ________________ Cell: ______________________ Parent/Guardian #2:___________________________________________________________________
Address: ______________________________________________________________________________ Telephone-Home: _______________________Work: ________________ Cell: ______________________ Other emergency contact: _____________________________________________________________
Address: _____________________________________________ Relationship: ______________________ Telephone-Home: _______________________Work: _________________ Cell: _____________________
Physician managing diabetes: _________________________________________________________
Address: _____________________________________________________________________________ Main Office #_________________ Fax #_________________ Emergency Phone #___________________ Nurse/Diabetes Educator: _________________________________________ Office # ___________________
Medical History
Parent/Guardian Response (check appropriate boxes and complete blanks)
♦ Snacks  ____AM  ____PM  _____Prior to Exercise/Activity  Student may determine if CHO counting  In the event of a class party may eat the treat (include insulin coverage if  student able to determine whether to eat the treat  replace with parent supplied treat  may NOT eat the treat  Other ___________________________________________________________  heart pounding  hunger  confusion  pale skin  headache  unconsciousness  change in mood or behavior  other _________________________________ Mild/Moderate  once a day  once a week  once a month
Indicate date(s) of last mild/moderate episode(s) ______________________________ What time of day is most common for hypoglycemia to occur? ___________________ Severe (i.e. unconscious, unable to swallow, seizure, or needed Glucagon)
Include date(s) of recent episode(s) ______________________________________
Parent/guardian will accompany child during field trips? hospitalizations this past year List any other medications currently being taken Allergies (include foods, I give permission to the school nurse and designated school personnel*, who have been trained and are under the
supervision of the school nurse to perform and carry out the diabetes care tasks as outlined in my child’s Diabetes
Medical Management Plan as ordered by the physician. I give permission to the designated school personnel, who
have been trained to perform the following diabetes care tasks for my child. (Code of Virginia§ 22.1-274).


I understand that I am to provide all supplies to the school necessary for the treatment of my child’s diabetes. I also
consent to the release of information contained in the Diabetes Medical Management Plan to 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. I also give permission to contact the above named physician and members of the diabetes management
team regarding my child’s diabetes should the need arise.
Parent/Guardian Name _____________________________________________
Date ________________
Parent/Guardian Signature_____________________________________________________________________

School Nurse’s Name ______________________________________________
Date ________________
School Nurse’s Signature _____________________________________________________________________
*Note: If at any time you would like to have the names of the designated school personnel that have been trained, please contact the school nurse. Names and training records are kept in the school clinic. DIABETES MEDICAL MANAGEMENT PLAN
Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service Part 3: Insulin Pump Supplement
Effective date:
To be completed by physician/provider, diabetes educator and parent/guardian. Student Name:
Pump Brand/Model: ™ Pump Company Technical Assistance Number: Pump Trainer/Resource Person: Phone/Beeper: Child-Lock On? No Code: _17_ (applicable to Cozmo Deltec™ Pump only) How long has student worn an insulin pump? __________________________ or Patient is new to pump therapy and is to initiate use of pump on _______ _____(date)
INSULIN / PUMP SETTINGS
Timing of Insulin Dose (Bolus Insulin):
Rapid-acting Insulin Type: ®
Rapid-acting Insulin should always be given prior to Use pump bolus calculator to determine all  If CHO intake cannot be predetermined insulin should be given no more meal, snack and correction doses unless set or than 30 minutes after completion of meal/snack.  Treat hypoglycemia before administration of meal or snack insulin. Calculating Insulin Doses: According to CHO ratio and Correction Factor (if needed) - the student requires meal time coverage with rapid-acting
insulin based on the amount of carbohydrates in meal and may require additional insulin to correct blood glucose to the desired range according to
the following formula:
Insulin Dose = [(Actual BG – Target pre-meal BG) divided by Insulin Sensitivity] + [# carbohydrates consumed/CHO Ratio]

• Fractional amounts of insulin from correction and carbohydrate calculation, when added together, may yield an even amount of insulin • If uneven, then round to the nearest whole unit (May use clinical discretion; if physical activity follows meal, then may round down).
Insulin Sensitivity/Correction Factor:
Target pre-meal BG: mg/dL
1 unit for every > target
CHO Ratio:
Exercise/PE CHO Ratio:
Not Applicable
• Less insulin may be required with meals prior to physical activity in order to prevent hypoglycemia. If so, the Exercise/PE CHO Ratio should be used instead of the CHO Ratio. Extra pump supplies to be furnished by parent/guardian: STUDENT PUMP SKILLS
Comments/Additional Instructions:

Calculate and administer correction bolus School nurses/personnel are not
routinely trained on use of specific
insulin pumps. School personnel will not
perform pump operation without training
(to be coordinated with school by
caregiver and healthcare provider). If
child is not independent and trained
RN/personnel are not available,
square/extended/dual/combo bolus features parent/guardian to be contacted for set
10. Use and programming of temporary basals for change. Insulin by injection until set is
changed per DMMP orders. If
11. Give injection with syringe or pen, if needed administering via injection, pump must be
suspended or disconnected unless
ordered otherwise.
13. Trouble shoot alarms and malfunctions Physician/Provider Signature: : Provider Printed Name: 2012-2013
SCHOOL YEAR
DIABETES MEDICAL MANAGEMENT PLAN
Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service
Part 3: Insulin Pump Supplement (continued)
Student Name:
HYPOGLYCEMIA MANAGEMENT (Low Blood Glucose):
Follow instructions in DMMP, but in addition: If seizure or unresponsiveness occurs:
1. Treat with Glucagon (See Diabetes Medical Management Plan)
2. Call 911 (or designate another individual to do so)
3. Stop insulin pump by any of the following methods (Send pump with EMS to hospital):
 Placing in “suspend” or stop mode (See manufacturer’s instructions)  Disconnecting at site, pigtail or clip  Cutting tubing 4. Notify parent 5. If pump was removed, send with EMS to hospital
HYPERGLYCEMIA MANAGEMENT (High Blood Glucose)

Follow instructions in diabetes medical management plan (DMMP), but in addition: Prevention of DKA (Diabetic Ketoacidosis)
If Blood Glucose (BG) is >250 mg/dL two times in a row, drink 8-16 oz. of water/hour and follow below:
Recheck ketones & BG every 1.5-2 hours ADDITIONAL TIMES TO CONTACT PARENT/GUARDIAN
 Soreness, redness or bleeding at infusion site
 Leakage of insulin at connection to pump or infusion site  Insulin injection given for high BG/ketones Other Instructions:

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. Physician/Provider Provider Printed Name: DIABETES MEDICAL MANAGEMENT PLAN
Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service
Part 4: Permission to Self-Carry and Self Administer Diabetes Care
To be completed by physician/provider, parent/guardian and student. This form is not required by law, but serves to inform
everyone of expectations and responsibilities.
Student Name: ___ Birthdate: ____________

Student’s physician or licensed nurse practitioner confirms that the student has a diagnosis of diabetes, is
independent and can perform diabetes care, and has approval to self-administer his/her diabetes care including:
insulin calculation and administration (including pump operation & pump equipment) The student understands that he/she is to promptly report to the school nurse or adult as soon as symptoms of high or low blood glucose appear or when not feeling well. I agree to prepare a written Diabetes Medical Management Plan in consultation with student’s parents and appropriate school personnel. Physician/Provider Signature: Provider Printed Name: 2012-2013
SCHOOL YEAR
____________________________________________________________________________________________
_

My child has been instructed in and understands his/her diabetic self-management. My child understands
that he/ she is responsible and accountable for carrying and using his/her medication and equipment.
I will provide the school nurse/school administrator with a copy of my child’s Diabetes Medical Management
Plan signed by his/her physician.
I hereby give permission for the school to administer the medications as prescribed in the care plan, if
indicated (ie. Student requests assistance or becomes unable to perform self-care).
I also give permission for the school to contact the above physician/nurse practitioner regarding my child’s
diabetes care (authorization required if contact is other than the school nurse).
I will not hold the school board or any of its employees liable for any negative outcomes resulting from the
self-administration of diabetes medication by my child.
I understand that the school nurse, after consultation with the parent/guardian and school administrator,
may impose reasonable limitations or restrictions upon my child’s possession and self-administration of
diabetes medications relative to his/her age and maturity or other relevant considerations.
I understand that the school administration may revoke permission to possess and self-administer said
diabetes medication at any point during the school year if it is determined that my child has abused the
privilege of possession and self-administration or he/she is not safely and effectively self-administering the
medication. In addition, my child could be subject to further disciplinary action.

______________________________________________ ______________________________________________ DIABETES MEDICAL MANAGEMENT PLAN
INTENSIVE THERAPY
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 regulations 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
9/7/2012
MONITORING
BLOOD GLUCOSE (BG)
For symptoms of hypo/hyperglycemia & MONITORING
Additional BG monitoring may be performed 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 POSSIBLE SIDE
TREATMENT OF SIDE
Additional Instructions:
Physician/Provider Signature: Provider Printed Name: 2012-2013
SCHOOL YEAR
DIABETES MEDICAL MANAGEMENT PLAN
INTENSIVE THERAPY
Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service
DIABETES SCHOOL CARE PLAN
Student:
Intensive Therapy/Multiple Daily Injections
Effective date: 9/7/2012
Definitions

Insulin-to-Carbohydrate Ratio
Insulin Sensitivity
Target Blood Glucose
(CHO Ratio)
(Correction Factor)
concentration after administration of 1 unit • usually expressed as “1 unit for every • usually expressed as “1 unit for every ____mg/dL blood glucose is > target” Insulin to be given during school hours: May calculate/give own injections with supervision Rapid-acting Insulin Type: ®
Timing of Insulin Dose:
(all doses to be administered subcutaneously) Rapid-acting Insulin should always be given prior to ® _____units at _____am or pm
 If CHO intake cannot be predetermined insulin should be given no more than 30 minutes after completion of meal/snack. (all doses to be administered subcutaneously)  Treat hypoglycemia before administration of meal or snack insulin. CALCULATING INSULIN DOSES: According to CHO ratio and Insulin Sensitivity/Correction Factor (if needed) - the student requires meal time
coverage with rapid-acting insulin based on the amount of carbohydrates in the meal and may require additional insulin to correct blood glucose
to the desired range according to the following formula:
Insulin Dose = [(Actual BG – Target pre-meal BG) divided by Insulin Sensitivity] + [# carbohydrates consumed/CHO Ratio]

• Fractional amounts of insulin from correction and carbohydrate calculation, when added together, may yield an even amount of insulin • If uneven, then round to the nearest half or whole unit (May use clinical discretion; if physical activity follows meal, then may round down).
Insulin Sensitivity/Correction Factor:
Target pre-meal BG: mg/dL
1 unit for every > target
Exercise/PE CHO Ratio:
Not Applicable
CHO Ratio:
Less insulin may be required with meals prior to physical activity in order to prevent hypoglycemia. If so, the Exercise/PE CHO Ratio should be used instead of the CHO Ratio. Correction insulin to be administered for elevated blood glucose if 3 hours or more after last insulin dose • In general, children with diabetes managed using Intensive Therapy/MDI do not require snacks. • 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 • 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 specifically noted. • A student should not exercise if his/her blood glucose is < 80 mg/dL or > 300 mg/dL (with positive ketones) immediately prior to exercise or until hypoglycemia/hyperglycemia is resolved. • A source of fast-acting glucose & glucagon should be available in case of hypoglycemia. Physician/Provider Signature: Provider Printed Name: 2012-2013
SCHOOL YEAR
DIABETES MEDICAL MANAGEMENT PLAN
INTENSIVE THERAPY
Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service DIABETES SCHOOL CARE PLAN
Student:
Effective date: 9/7/2012

Hypoglycemia (Low Blood Glucose)
Hypoglycemia is defined as a blood glucose < mg/dL
Signs of hypoglycemia:
• If hypoglycemia is 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 grams 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 Meal CHO per orders • If BG in acceptable range and not lunch or snack time, provide student slowly-released CHO snack (Example: 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 to small (blood ketones 0 - 1mmol/L), give 8-16 ounces of sugar-free fluid Hyperglycemia
• If correction insulin has not been administered within 3 hours, provide correction insulin according to Management
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 >1mmol/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://kgcs.k12.va.us/forms/diabetes_plan.pdf