Diabetes Medical Management Plan (Dmmp) Template Page 6
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7Additional information for student with insulin pump
(continued)
Student’s Self-care Pump Skills
Independent?
Counts carbohydrates
Yes
No
Calculates correct amount of insulin for carbohydrates consumed
Yes
No
Administers correction bolus
Yes
No
Calculates and sets basal profiles
Yes
No
Calculates and sets temporary basal rate
Yes
No
Changes batteries
Yes
No
Disconnects pump
Yes
No
Reconnects pump to infusion set
Yes
No
Prepares reservoir, pod, and/or tubing
Yes
No
Inserts infusion set
Yes
No
Troubleshoots alarms and malfunctions
Yes
No
Other diabetes medications
Name: ________________________ ________ Dose: ______________ Route: ______________ Times given: ______________
Name: ________________________ ________ Dose: ______________ Route: ______________ Times given: ______________
Meal plan
Meal/Snack
Time
Carbohydrate Content (grams)
____ to ____
Breakfast
____ to ____
Mid-morning snack
____ to ____
Lunch
____ to ____
Mid-afternoon snack
Other times to give snacks and content/amount: ______________ _ _____________________________________________
_____________________________________________________________________________________________________
Instructions for when food is provided to the class (e.g., as part of a class party or food sampling event): _______________
___________________________________________________________________________________ _ __________________
Special event/party food permitted:
Parents’/Guardians’ discretion
Student discretion
Student’s self-care nutrition skills:
Independently counts carbohydrates
May count carbohydrates with supervision
Requires school nurse/trained diabetes personnel to count carbohydrates
Page 6 of 7, DMMP
Tools for Effective Diabetes Management
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