Diabetes Medical Management Plan (School Orders/DMMP)

Student: [Full name], DOB: [MM/DD/YYYY], Grade/School: [Grade and school name]

Diabetes Type: [T1D / T2D / Other: specify] — Diagnosis date: [MM/YYYY]

DMMP Valid: [School year or date range] — Supersedes prior DMMP dated: [MM/DD/YYYY or N/A if none]

Provider: Clinic: [Clinic name]; Clinician: [Name, credentials]; Phone: [###-###-####]; Fax: [###-###-####]

Emergency Contacts (in priority order):

Priority	Name/Relationship	Phone(s)	Notes
1	[Name, relationship]	[Primary] / [Alternate]	[Preferred contact times or instructions]
2	[Name, relationship]	[Primary] / [Alternate]	[Notes]
3	[Name, relationship]	[Primary] / [Alternate]	[Notes]

Clinical Risk Indicators

• History of severe hypoglycemia (LOC/seizure/glucagon use) in past 2 years: [Yes / No / Unknown] — Date of last event: [MM/DD/YYYY] (Select "Unknown" rather than leaving blank if history is uncertain.)
• History of DKA or diabetes hospitalization in past 2 years: [Yes / No / Unknown] — Date of last event: [MM/DD/YYYY] (Select "Unknown" rather than leaving blank if history is uncertain.)
• Hypoglycemia unawareness: [Yes / No / Unknown]
• Relevant comorbidities affecting school care: [Comorbidities, if any]

Supervision Level & Care Responsibilities

Overall supervision designation: [Full Support (staff performs all tasks) / Supervision (staff assists, encouraging independence) / Self-Care (student performs independently with support as needed)]

Task	Performs	Assists	Parent Notification Required	Comments
Glucose monitoring	[Student / School Nurse / Trained Personnel]	[Student / School Nurse / Trained Personnel / N/A]	[Yes / No]	[Location of supplies, device specifics]
Hypoglycemia/hyperglycemia response	[Student / School Nurse / Trained Personnel]	[Student / School Nurse / Trained Personnel / N/A]	[Yes / No]	[Escalation steps]
Carb counting	[Student / School Nurse / Trained Personnel]	[Student / School Nurse / Trained Personnel / N/A]	[Yes / No]	[Source of carb info, menu access]
Insulin administration	[Student / School Nurse / Trained Personnel]	[Student / School Nurse / Trained Personnel / N/A]	[Yes / No]	[Delivery method, verification steps]
Device troubleshooting (meter/CGM/pump)	[Student / School Nurse / Trained Personnel]	[Student / School Nurse / Trained Personnel / N/A]	[Yes / No]	[When to call parent/clinic]
Emergency response (severe hypo/hyperglycemia)	[School Nurse / Trained Personnel]	[Student / School Nurse / Trained Personnel / N/A]	[Yes / No]	[911 activation criteria, supervision requirements]

Glucose Monitoring

Monitoring Method:

• Blood glucose meter: [Yes / No] — Location: [Clinic / Classroom / Backpack / Other]
• CGM: [Yes / No] — Brand/model: [Brand and model] — Remote monitoring by school staff: [Not used / Optional / Medically necessary]

When to Check Glucose:

• [✓ / —] Before meals/snacks
• [✓ / —] Before/after physical activity
• [✓ / —] With symptoms or CGM alarms
• [✓ / —] Before leaving school/bus
• [✓ / —] Other: [Specify]

Confirmatory Fingerstick Required (if CGM used): When symptoms do not match sensor, sensor unavailable or inconsistent, persistent low (<70 mg/dL) after 15-minute recheck, or at extremes per clinic protocol.

Insulin Delivery & Medications

• Delivery Method: [MDI (pen/syringe) / Insulin pump] — Brand/model: [Brand and model] — AID system: [Yes / No]
• Insulins:
  • Rapid/short-acting: [Insulin name]
  • Long-acting (if given at school): [Insulin name], dose [Number] units, time [Time of administration] (Write "units" in full; use leading zeros such as 0.5; avoid trailing zeros.)
  • Pump failure backup plan: [Injection dosing instructions and contact steps]
• Other Diabetes Medications (if given at school): [Drug name, dose, route, time, frequency] (Write "units" in full; use leading zeros; avoid trailing zeros.)

Insulin Dosing Orders

Dose Calculation Method: [Ratio-based / Fixed dose / Pump/bolus calculator determines dose (staff enters carbs and verifies)] (Select one per time block)

Time Block	Carb Ratio OR Fixed Dose	Target Glucose (mg/dL)	Correction Factor OR Sliding Scale	Notes
Breakfast	[1 unit per __ g carb / Fixed: __ units]	[Target]	[__ mg/dL per unit / See sliding scale]	[Pre-bolus timing, typical variations]
Lunch	[1 unit per __ g carb / Fixed: __ units]	[Target]	[__ mg/dL per unit / See sliding scale]	[Notes]
Snacks/Other	[1 unit per __ g carb / Fixed: __ units / No insulin for snack]	[Target]	[__ mg/dL per unit / See sliding scale]	[Notes]

(Write "units" in full for all insulin doses; use leading zeros such as 0.5; avoid trailing zeros.)

Sliding Scale Table (if used instead of correction factor):

Glucose Range (mg/dL)	Additional Insulin (units)	Notes
[Lower]–[Upper]	[Dose] units	[Notes]
[Lower]–[Upper]	[Dose] units	[Notes]
[Lower]–[Upper]	[Dose] units	[Notes]

Dose Timing: [Pre-meal (__ minutes before) / At meal / Post-meal (for unpredictable intake)]

Incomplete Meal Rule: Require substitution carbs: [Yes / No] — How substitution is determined: [Equivalence method or nurse call procedure]

Correction Dosing:

• Formula: (Actual glucose – Target) ÷ Correction factor = units, OR use sliding scale table above
• Minimum interval between corrections: [Number] hours
• No correction dose ordered: [Yes / No]

Ketone Check Before Correction: Required if glucose > [Threshold] mg/dL

Authorized Dose Adjustments:

• Parent/guardian may adjust: [Yes / No] — Bounds: [± units or percentage]
• School nurse may adjust: [Yes / No] — Bounds: [± units or percentage]

⚠ Safety Check: If any dosing parameter (carb ratio, correction factor, or target) is missing, mark this DMMP as INCOMPLETE and contact the provider before administering insulin.

Hypoglycemia (Low Glucose) Management

Treatment Threshold: Treat if glucose < [Threshold] mg/dL (or < [Activity threshold] mg/dL during activity, if different)

Standard Treatment Protocol:

1. Give [Number] grams fast-acting carbohydrate (examples: [School-available options])
2. Recheck glucose in 15 minutes
3. Repeat treatment if still below [Threshold] mg/dL
4. Once glucose > [Recovery threshold] mg/dL, give follow-up snack: [Carb/protein specification] (If indicated)

Severity Levels:

• Mild (conscious, able to swallow): Follow standard treatment protocol
• Severe (unable to swallow, seizure, or unconscious): Administer glucagon → Position on side → Call 911 → Notify parent/guardian → If pump in use: suspend/disconnect per plan below

Glucagon/Emergency Medication Order:

• Product: [Nasal glucagon / Auto-injector / Glucagon kit / Not prescribed]
• Dose: [Dose per product instructions]
• Pump action during severe low: [Suspend / Disconnect / Other: specify]

(If glucagon is not prescribed, state: "Glucagon not prescribed — Call 911 for severe hypoglycemia.")

⚠ Do not leave the student alone during suspected or confirmed hypoglycemia.

Hyperglycemia (High Glucose) & Ketone Management

Action Threshold: Intervene if glucose > [Threshold] mg/dL, or if symptomatic regardless of glucose

Ketone Testing Triggers: Glucose > [Threshold] mg/dL, illness/vomiting, or pump failure suspected

Management by Ketone Level:

• Negative/trace: Encourage sugar-free fluids, give correction dose per dosing orders, may return to class if feeling well
• Small: Give correction dose, encourage fluids, recheck ketones in [Number] hours, notify parent/guardian, no vigorous activity
• Moderate/large: Give correction by INJECTION (not pump), notify parent/guardian immediately, contact clinic, no physical activity, change pump site if applicable

⚠ Call 911 if: Labored/rapid breathing, altered mental status, persistent vomiting, or unable to keep fluids down

Pump Failure Contingency (if pump user): Suspect pump failure if glucose remains high despite correction, or site issues. Give correction by injection: [Number] units. If AID system, turn off automation for [Number] hours after manual injection. (If applicable)

Physical Activity & Sports

• Participation: [Permitted without restriction / Permitted with restrictions below / Not permitted: specify reason]
• Glucose Checks: Before activity: [Yes / No] — After activity: [Yes / No] — During prolonged activity (>30 min): [Yes / No]
• Pre-Activity Snack: [Number] grams carbohydrate if glucose < [Threshold] mg/dL
• Activity-Related Adjustments (if permitted): Temporary target/activity mode: [Setting] — May suspend/disconnect pump for up to [Number] minutes: [Yes / No]
• Avoid Activity If: Glucose > [Threshold] mg/dL with ketones, glucose > [Threshold] mg/dL (even without ketones), or within [Number] minutes of treating severe hypoglycemia

⚠ Fast-acting carbohydrates must be immediately accessible at the activity site.

Supplies & Emergency Preparedness

• Required Supplies at School: Glucose meter and supplies (required even for CGM users), fast-acting carbohydrate, glucagon/emergency medication, ketone testing supplies, insulin and delivery supplies, pump supplies (if applicable)
• Storage: Insulin stored at: [Location]. Glucagon stored at: [Location]. (Treatment supplies must be immediately accessible, not locked without rapid access.)
• Disaster/Evacuation: Minimum supply duration for go-bag: [Number] hours. Responsible party for transporting supplies: [Name/role]. Follow DMMP orders unless superseded by emergency protocol.

Authorizations & Signatures

Parent/Guardian Authorization: I authorize school nurse and trained school personnel to perform diabetes care tasks as specified in this DMMP. I consent to share DMMP information with staff responsible for my child's safety on a need-to-know basis.

Parent/Guardian Signature: ___________________________ Date: [MM/DD/YYYY]

Provider Certification: I certify these orders are individualized for this student. Only authorized clinicians may modify these orders.

Provider Signature: ___________________________ Printed Name: [Name] Credentials: [Credentials] Date: [MM/DD/YYYY]

School Nurse Acknowledgment: (Optional)

School Nurse Signature: ___________________________ Date: [MM/DD/YYYY]