Diabetes Medical Management Plan (Dmmp) Template Page 2
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7Checking blood glucose
Brand/model of blood glucose meter: ______________________________________ _______________________________
Target range of blood glucose:
Other: __________
Before meals:
90–130 mg/dL
Check blood glucose level:
Before breakfast
After breakfast
____ Hours after breakfast
2 hours after a correction dose
Before lunch
After lunch
____ Hours after lunch
Before dismissal
Mid-morning
Before PE
After PE
Other: __________
As needed for signs/symptoms of low or high blood glucose
As needed for signs/symptoms of illness
Preferred site of testing:
Side of fingertip
Other: __________
Note: The side of the fingertip should always be used to check blood glucose level if hypoglycemia is suspected.
Student’s self-care blood glucose checking skills:
Independently checks own blood glucose
May check blood glucose with supervision
Requires a school nurse or trained diabetes personnel to check blood glucose
Uses a smartphone or other monitoring technology to track blood glucose values
Continuous glucose monitor (CGM):
Yes
No Brand/model: ____________ _ ______ _ _________________________ _
Alarms set for:
Severe Low: _____ _________ Low: _____ _________ High: _____ _________
Predictive alarm: Low: _____ _________ High: _____ ____ _____ Rate of change: Low: _____ _________ High: _____ ____ _____
Threshold suspend setting: __________________________________ _ _____________________________________________
Additional information for student with CGM
•
Confirm CGM results with a blood glucose meter check before taking action on the sensor blood glucose level.
If the student has signs or symptoms of hypoglycemia, check fingertip blood glucose level regardless of the CGM.
•
Insulin injections should be given at least three inches away from the CGM insertion site.
•
Do not disconnect from the CGM for sports activities.
•
If the adhesive is peeling, reinforce it with approved medical tape.
•
If the CGM becomes dislodged, return everything to the parents/guardians. Do not throw any part away.
•
Refer to the manufacturer’s instructions on how to use the student’s device.
Student’s Self-care CGM Skills
Independent?
The student troubleshoots alarms and malfunctions.
Yes
No
The student knows what to do and is able to deal with a HIGH alarm.
Yes
No
The student knows what to do and is able to deal with a LOW alarm.
Yes
No
The student can calibrate the CGM.
Yes
No
The student knows what to do when the CGM indicates a rapid trending rise or
Yes
No
fall in the blood glucose level.
The student should be escorted to the nurse if the CGM alarm goes off:
Yes
No
Other instructions for the school health team: __________________________ _______________________________________
_____________________________________________________________________________________________________
Page 2 of 7, DMMP
Tools for Effective Diabetes Management
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