Diabetes Medical Management Plan (Dmmp) Template Page 5
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7Insulin therapy
(continued)
Fixed Insulin Therapy Name of insulin: ___________________________________________________________________ _
______ Units of insulin given pre-breakfast daily
______ Units of insulin given pre-lunch daily
______ Units of insulin given pre-snack daily
Other: __________
Parents/Guardians Authorization to Adjust Insulin Dose
Yes
No Parents/guardians authorization should be obtained before administering a correction dose.
Yes
No Parents/guardians are authorized to increase or decrease correction dose scale within the following range:
+/– ______ units of insulin.
Yes
No Parents/guardians are authorized to increase or decrease insulin-to-carbohydrate ratio within the following
range: ______ units per prescribed grams of carbohydrate, +/– ______ grams of carbohydrate.
Yes
No Parents/guardians are authorized to increase or decrease fixed insulin dose within the following range:
+/– ______ units of insulin.
Student’s self-care insulin administration skills:
Independently calculates and gives own injections.
May calculate/give own injections with supervision.
Requires school nurse or trained diabetes personnel to calculate dose and student can give own injection with supervision.
Requires school nurse or trained diabetes personnel to calculate dose and give the injection.
Additional information for student with insulin pump
Brand/model of pump: ________________________________ Type of insulin in pump: __________ ______________________
Basal rates during school: Time: _________ Basal rate: __________
Time: _________ Basal rate: __________
Time: _________ Basal rate: __________
Time: _________ Basal rate: __________
Time: _________ Basal rate: __________
Other pump instructions: __________________________________________________________________________ _____
____ ___________________________________________________________________________________________ _______
Type of infusion set: ______ ______________________________________________________________________________
Appropriate infusion site(s): _____________________ _________________________________________________________
For blood glucose greater than ______ mg/dL that has not decreased within ____ hours after correction, consider pump
failure or infusion site failure. Notify parents/guardians.
For infusion site failure: Insert new infusion set and/or replace reservoir, or give insulin by syringe or pen.
For suspected pump failure: Suspend or remove pump and give insulin by syringe or pen.
Physical Activity
May disconnect from pump for sports activities:
Yes, for ____ hours
No
Set a temporary basal rate:
Yes, ____ % temporary basal for ____ hours
No
Suspend pump use:
Yes, for ____ hours
No
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Tools for Effective Diabetes Management
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