Diabetes Medical Management Plan (DMMP) Forms

Name of InstitutionInstitution AddressDepartmentDIABETES MEDICAL MANAGEMENT PLANINTENSIVE THERAPYPage 1 of 3Part 2: Virginia Diabetes Medical Management Plan (DMMP)To be completed by physician/provider.Patient Label or MRN, Acct#, Patient Name, DOB, Date of ServiceNotice to Parents: Medication(s) MUST be brought to school by the PARENT/GUARDIAN in a container that is appropriately labeledby the pharmacy or physician/practitioner.In order for schools to safely administer medication during school hours, the following regulations should be observed:‣ A new copy of the DMMP must be completed at the beginning of each school year. This form, an Authorization forMedication Administration form, or MD prescription must be received in order to change diabetes care at school during theschool year.Student Name (Last, First, MI)Student’s Date of BirthSchool Student’s Grade Home PhoneParent NameWork/Cell PhoneHome Address City State, Zip codeStudent’s Diagnosis: DIABETES: Type 1 Type 2OtherToday’s Date8/19/2011BLOOD GLUCOSE (BG)MONITORING with meter, lancets,lancing device, and test stripsYesMONITORINGNoStudent requires supervisionTo be performed by schoolpersonnelStudent is independentPermission to self-carryBefore mealsFor symptoms of hypo/hyperglycemia &anytime the student does not feel wellBefore PE/ActivityAfter PE/ActivityPrior to dismissalAdditional BG monitoring may be performedat parent’s requestCONTINUOUS GLUCOSEMONITORING (CGM)Brand/Model:YesAlarms set for:NoLow:_____ (mg/dL)High:_____ (mg/dL)Always confirm CGM results with finger stickcheck before taking action on sensor bloodglucose level. If student has symptoms or signsof hypoglycemia, check finger stick bloodglucose level regardless of CGM.URINE KETONE TESTINGBLOOD KETONE TESTINGAnytime the BG >mg/dL or when student complains of nausea, vomiting,abdominal pain. See page 3 for further instructions under hyperglycemiamanagement.NAME OF MEDICATION DOSE/ROUTE TIMEGLUCAGON - INJECTABLEGlucophage ® (Metformin)to be administered at schoolOther:to be administered at schoolAdditional Instructions:®0.5 mg subq/IM1.0 mg subq/IMDOSAGEmg poTIMEAM or PMImmediately for severe hypoglycemia:unconscious, semi-conscious (unable tocontrol his/her airway or unable to swallow),or seizingPOSSIBLE SIDEEFFECTSNausea/vomiting,diarrheaTREATMENTOFSIDEEFFECTSClear liquidsSpecific duration of order:2009-2010SCHOOL YEARInstitution Form #Physician/Provider Signature: Provider Printed Name: Office Phone: XXX-XXX-XXXXOffice Fax: XXX-XXX-XXXXEmergency # XXX-XXX-XXXX8