Medical Authorization Form For Diabetic Management Form
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2Attachment 1 Reg. No. 400-80
FREDERICK COUNTY PUBLIC SCHOOLS/FREDERICK COUNTY HEALTH DEPARTMENT
MEDICAL AUTHORIZATION FORM FOR DIABETIC MANAGEMENT
This order is valid only for the Current School Year___________(Including summer session)
Student:
Date of Birth:
School:
Grade:
BLOOD GLUCOSE (BG) MONITORING
Target for blood
Check Glucose: Before snacks
Before meals
glucose at school:
____ hours after lunch
____ hours after a correction dose
________________
As needed for symptoms of hypo/hyperglycemia
With signs and symptoms of illness
Other times:
Hypoglycemia =
Self treatment for mild lows.
Suspend pump for severe hypoglycemia for __________min.
blood glucose less
Give _______ grams of fast-acting carbohydrate according to care plan. Recheck BG in 10-15 mins.
than:
Repeat treatment if BG less than _________mg/dl
________________
Provide extra protein & carbohydrate snack after treating low if next meal/snack greater
than ________minutes away.
If student is
Glucagon injection (1 mg in 1 cc) ______________mg, subcutaneously (SQ) or intramuscular (IM)
unconscious, seizing
OK to use glucose gel inside cheek, even if unconscious, seizing.
or unable to
Other:
swallow, call 911
and notify parent.
Hyperglycemia =
Check urine ketones, follow emergency care plan, and administer insulin as per orders.
blood glucose greater
Encourage sugar free fluids, at least ________________ounces per_______________.
than:
For pumps, insulin may be given by syringe or pen if needed and follow insulin orders below.
_________________
If student complains of nausea, vomiting or abdominal pain; follow urine ketones and insulin
orders below.
Other ______________________________________________________________________
INSULIN ORDERS
(Complete Only if Insulin is Needed at School)
Insulin Administration Via:
Syringe and vial
Insulin pen
Insulin pump: Type of pump__________________________Basal rates_____________
Other:
Give Insulin As Indicated Below:
Name of Insulin: _______________________________________________________
Routine lunchtime dose: ___________________________ Routine breakfast dose: ______________________________
Per sliding scale as follows:
Blood Glucose
To
Give
Units
Additional/Alternative Calculations
Blood Glucose
To
Give
Units
Blood Glucose
To
Give
Units
Blood Glucose
To
Give
Units
Blood Glucose
To
Give
Units
Blood Glucose
To
Give
Units
Blood Glucose
To
Give
Units
Blood Glucose
To
Give
Units
Blood Glucose
To
Give
Units
Calculated insulin dose (add carbohydrate coverage and correction dose for total insulin dose):
Carbohydrate Coverage: Insulin to carbohydrate ratio Give ____________# unit(s) insulin per ___________gms carbohydrates
Correction: Give ______________# unit(s) insulin per _____________mg/dl of glucose above ______________mg/dl
Subtract____________# unit(s) for every ______________mg/dl of glucose below_______________mg/dl
1-2 units insulin may be added/subtracted at parent/student discretion
Other times insulin may be given:
Routine Snack:
Dose:__________________
Calculated on sliding scale above
Ketones:
If ketones are _____________ give ________ unit(s)
Hyperglycemia: If blood glucose is greater than __________ give ____________ units of insulin
OR Use sliding scale above OR Use correction formula above
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