Diabetes Care Plan For Child/student On An Insulin Pump Template Page 2
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1
2INSULIN PUMP BOLUS ADMINISTRATION
Yes
No
Does the student require insulin pump boluses at school?
Insulin pump boluses are not required at school if the student’s pump has been programmed to automatically deliver
extra insulin for recess and lunch. If the pump has been programmed to automatically deliver extra insulin for recess
and lunch, it is essential that recess and lunch are eaten on time.
Yes
No
If Yes, is supervision required for the student?
Supervision of insulin pump boluses is recommended for all primary school students, to ensure the
correct amount of carbohydrate and the correct blood glucose level is entered into the pump.
Staff to supervise and support as follows:
INSULIN ADMINISTRATION INSTRUCTIONS
TIME
(please print clearly)
please tick administration time(s)
Medication name
07 – 08.30
(include generic name)
am
09 – 10.30
am
The
flexibility
11 – 12.30
am
Form
Route
(eg liquid, tablet, capsule, cream)
(eg oral, inhaled, topical)
in times
01 – 02.30
liquid
pump
pm
allows
pump
03 – 04.30
pm
planning
Strength
Dose
05 – 06.30
around
pm
activities
07 – 08.30
pm
Other instructions for administration
Overnight
Other
(if medically necessary)
Please specify:
Start/finish date
(if appropriate) from
to
________________
Authorised prescriber _________________________________ Professional role _________________________________
Address ___________________________________________________________________________________________
___________________________________________________________________ Telephone ____________________
Signature ____________________________________________________________ Date _________________________
THIS PLAN HAS BEEN DEVELOPED FOR THE FOLLOWING SERVICES/SETTINGS
School/education
Respite/accommodation
Transport
(please specify)
Childcare
Outings/camps/holidays/aquatics/swimming
Other
AUTHORISATION AND RELEASE
Medical Professional/Diabetes Educator ___________________________ Professional role _____________________________
Address ____________________________________________________________________________________________________
___________________________________________________________________ Telephone _____________________________
Signature ___________________________________________________________ Date _________________________________
I have read, understood and agreed w ith this plan and any attachments indicated above.
I approve the release of this inform ation to supervising staff and em ergency medical personnel.
Parent/guardian
_____________________________________________________ Signature _________________________ Date _____________
Family name (please print)
First name (please print)
DECD Diabetes care plan insulin pump June 2013
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