Diabetes Medical Management Plan Template
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1
2Institution Name and Address:
DIABETES MEDICAL MANAGEMENT PLAN
Patient Label or MRN, Acct#, Patient name, DOB, Date of Service
Page 1 of 2
Effective date: ___________
Part 3: Insulin Pump Supplement
To be completed by physician/provider, diabetes educator and parent/guardian.
Student Name:
Date of Birth:
Pump Brand/Model:
™
Pump Company Technical Assistance Number:
Pump Trainer/Resource Person:
Phone/Beeper:
Child-Lock On?
Yes
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
meals
snacks
if CHO intake can be predetermined.
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.
pump malfunction occurs.
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)
Insulin Sensitivity] + [# carbohydrates consumed/CHO Ratio]
divided by
• 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 or half unit (May use clinical discretion; if physical activity follows meal, then may round down).
•
Insulin Sensitivity/Correction Factor:
Target pre-meal BG:
mg/dL
unit for every
> target
Parent has permission
CHO Ratio:
Exercise/PE CHO Ratio:
Not Applicable
to adjust CHO ratio in a
Less insulin may be required with meals prior to physical activity in
•
range from
order to prevent hypoglycemia. If so, the Exercise/PE CHO Ratio
1:
to
should be used instead of the CHO Ratio.
1:
Extra pump supplies to be furnished by parent/guardian:
infusion sets
reservoirs
pods for OmniPod™
dressings/tape
insulin
syringes/insulin pen
pump manufacturer instructions
Comments/Additional Instructions:
STUDENT PUMP SKILLS
1.
Count carbohydrates
Independent
Needs Assistance
2.
Bolus for carbohydrates consumed
Independent
Needs Assistance
3.
Calculate and administer correction bolus
Independent
Needs Assistance
4.
Disconnect pump
Independent
Needs Assistance
5.
Reconnect pump at infusion set
Independent
Needs Assistance
School nurses/personnel are not
routinely trained on use of specific
6.
Access bolus history on pump
Independent
Needs Assistance
insulin pumps. School personnel will not
7.
Prepare reservoir and tubing
Independent
perform pump operation without training
(to be coordinated with school by
8.
Insert infusion set
Independent
caregiver and healthcare provider). If
9.
Use & programming of
child is not independent and trained
Independent
Needs Assistance
square/extended/dual/combo bolus features
RN/personnel are not available,
10. Use and programming of temporary basals for
parent/guardian to be contacted for set
Independent
Needs Assistance
exercise and illness
change. Insulin by injection until set is
changed per DMMP orders. If
11. Give injection with syringe or pen, if needed
Independent
Needs Assistance
administering via injection, pump must be
12. Re-program pump settings if needed
Independent
Needs Assistance
suspended or disconnected unless
ordered otherwise.
13. Trouble shoot alarms and malfunctions
Independent
Needs Assistance
Institution Form #
Specific duration of
:
Physician/Provider Signature: :
Provider Printed Name
Office Phone: ____________
order:
Office Fax:
____________
2009-2010
Emergency # ___________
SCHOOL YEAR
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