Child Care Diabetes Medical Management Plan
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1
2Child Care Diabetes
Medical Management Plan
Name of Child: ________________________________________
DOB: __________ Dates Plan in Effect: ______________
Parent or guardian Name(s)/Number(s): _____________________________________________________________________
Diabetes Care Provider Name/Number: ______________________________________________________________________
Diabetes Care Provider Signature: _______________________________________________________ Date: ______________
Location of diabetes supplies at child care facility: _____________________________________________________________
Blood Glucose Monitoring
Target range for blood glucose is:
80-180
Other ________________________________________________________
When to check blood glucose:
before breakfast
before lunch
before dinner
before snacks
When to do extra blood glucose checks:
before exercise
after exercise
when showing signs of low blood glucose
when showing signs of high blood glucose
other ______________________
Insulin Plan:
Please indicate which type of insulin regimen this child uses (check one):
Insulin Pump
Multiple Daily Injections
Fixed Insulin Doses
Specific information related to each insulin regimen/plan is included below for this child.
Type of insulin used at child care (check all that apply):
Regular
Apidra
Humalog
Novolog
NPH
Lantus
Levemir
Mix
Other ______________
Plan A: Insulin Pump*
Plan B: Multiple Daily Injections
C: Fixed Insulin Doses
1. Always use the insulin pump bolus
1. Child will receive a fixed dose of
1. Child will receive a fixed dose of long
wizard:
Yes
No
__________ long-acting insulin at
acting insulin?
Yes
No
If no, use Insulin:Carbohydrate Ratio and
__________
Yes
No
If yes, give child _________ units of
Correction Factor dosage on Plan B.
_________ insulin at _________.
2. Follow blood glucose monitoring
2. Blood glucose must be checked before
plan above.
2. Insulin correction dose at child care
the child eats and will (check one):
( _________ insulin)?
3. Use _____________ insulin for meals
Be sent to the pump by the meter
Yes
No
and snacks. Insulin dose for food is
Need to be entered into the pump
_____ unit(s) for meals OR
3. If blood glucose is above target, add
3. The insulin pump will calculate the
_____ unit(s) for every _____ grams
correction dose to:
correction dose to be delivered before
carbohydrate.
Breakfast
Snack
the meal/snack.
Give injection after the child eats.
Lunch
Snack
Other: _____________________
4. After the meal/snack, enter the total
4. If blood glucose is above target, add
Use the following correction factor
number of carbohydrates eaten at
correction dose to:
_____________ or the following
that meal/snack. The insulin pump will
Breakfast
Snack
scale:
calculate the insulin dose for the meal.
Lunch
Snack
_____ units if BG is _____ to _____
Other: _____________________
5. Contact parent/guardian with any
_____ units if BG is _____ to _____
Use the following correction factor
concerns.
_____ units if BG is _____ to _____
_____________ or this scale:
For a list of definitions of terms used in
_____ units if BG is _____ to _____
_____ units if BG is _____ to _____
this document, please see the Diabetes
Only add correction dose if it has
_____ units if BG is _____ to _____
Dictionary.
been 3 hours since the last insulin
_____ units if BG is _____ to _____
administration.
*Providers should complete
_____ units if BG is _____ to _____
Insulin:Carbohydrate ratio and
Only add correction dose if it has
Correction dosage under Plan B
been 3 hours since the last insulin
section for ALL pump users.
administration.
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