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JOHNS COUNTY SCHOOL DISTRICT HEALTH SERVICES ! FOR DIABETES MEDICAL MANAGEMENT PLAN My signature below provides authorization for this Diabetes Medical Management Plan. FOR DIABETES MEDICAL MANAGEMENT PLAN My signature below provides authorization for this Diabetes Medical Management Plan. Review with relevant school staff and ask that copies be kept in a place easily accessed by other school personnel. This Seizure Medical Management Plan has been approved by: _____ _____ _____ Healthcare Provider Date E-mail . !F%p�>I�z�M�e~2�Y.m>����Δ� 52 Helping the Student with Diabetes Succeed Diabetes Medical Management Plan Continued Hypoglycemia (Low Blood Sugar) Usual symptoms of hypoglycemia: Treatment of hypoglycemia: Glucagon should be given if the student is unconscious, having a seizure (convulsion), or … Part B: Diabetes Medical Management Plan. Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. I have reviewed this information form and agree with the indicated information. DIABETES MANAGEMENT PLAN Diabetes NSW & ACT - 1300 136 588 Emergency Management Refer to student’s individualised ACTION PLAN for treatment in conjunction with the below details. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel. I have reviewed this medical management plan and agree with the indicated instructions. We (I), the undersigned, the parent(s)/guardian(s) of the above named child, request that this Diabetes Medical Management Plan, and any modification thereto, be implemented while our (my) child is at school or attending a school-related event on or off campus. Date of Plan: _____ Diabetes Medical Management Plan This plan should be completed by the student’s personal health care team and parents/guardian. Child will receive a fixed dose of _____ long-acting insulin at _____ Yes No 2. %PDF-1.5 the diabetes care tasks for my child as outlined in my child’s Diabetes Medical Management Plan as ordered by the prescribing health care provider. Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardian. This section must be completed by the student’s physician or advanced practice nurse and provides the medical “orders” for the student’s care. Diabetes Medical Management Plan . I understand that in some school districts specialized health care services may be observed by unlicensed designated school personnel under the training provided by a school nurse or RN. %%EOF outlined in this Diabetes Medical Management Plan and/or 504 Medical Plan and for my child’s healthcare provider to share information with the school for completion of this plan. �r � �f+�J U �.H�Dx��`�V "H؁X̾@�+H�o�@B�:�`�$�Y�.��e`�!�q�[� �=] This!plan!should!be!completed!by!the!student’s!parent(s)/guardian(s)!and!the!diabetes! 0 I have reviewed this medical management plan and agree with the indicated instructions. Diabetes Medical Management Plan C:\Users\gutierrez.jon\Desktop\Website Documents 201718\Diabetes_ManagementPlan for School.doc Hypoglycemia Self treatment of mild lows Assistance for all lows Immediately treat with 15 gm of fast-acting carbohydrate (e.g., 4 oz juice, 3-4 glucose tabs, 4 oz regular soda, 8 oz skim milk) Important actions. 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The Diabetes UK Management Plan protocols need to be activated and will generate a pop up alert for patients if they are pregnant, have a Kidney Disease or have a raised BP/HbA1c/Cholesterol value, and no record of a diabetes management plan in the last 6 months, no record of a eGFR or ACR test in It is the Even though resources vary widely within the Region, the primary resource in diabetes care is now recognized to be the people with diabetes themselves, supported by well trained and enthusiastic health care professionals. Diabetes Medical Management Plan Author: Division of Student Support, Academic Enrichment,and Educational Policy Subject: Diabetes Medical Management Plan Keywords: Diabetes Medical Management Plan Created Date: 7/9/2020 11:32:57 AM Authorization to Conduct Blood Glucose Testing in Location other than the Clinic The following diabetes supplies should be available to the student during school-sponsored activities: A copy of the student’s Diabetes Medical Management Plan (DMMP), Section 504 Plan, Emergency Action Plan, and Healthcare Plan Injection/insulin pump supplies and insulin with appropriate storage to prevent spoilage of insulin �6�T. 68 0 obj <> endobj �&��$�v?x�&�̀'�����h �j�2ȑ���($v ���sR�K�\��T�z��_]��B,�ݫtQ���6OƳ�Ʒ�M_��7U��B��"��j�-�g�A����bs����LΣ��(��D��������A��n����0� �R�Tkt+�(|����Ԟ#Hd8�la#Xd�0"6�xA� ����6 �E���� (Code of Virginia § 22.1-274) Parent authorization for trained school designees to administer: *Providers should complete Insulin:Carbohydrate ratio and Correction dosage under Plan B section for ALL pump users. %PDF-1.7 %���� This form will assist the school health personnel in developing a nursing care plan. *RevisedSeptember!2013!! ��Hb�W��Ti��=T[Tg&P�1j���`�"���87(l�c6P�64�5e�/}�����۸�8�x��M� Follow blood glucose monitoring plan … DIABETES(MEDICAL(MANAGEMENT(PLAN(DMMP)((For(Student(RequiringInsulinTherapy(!! I understand that in some school districts specialized health care services may be observed by unlicensed designated school personnel under the training provided by a school nurse or RN. Date of Plan: _____ Diabetes Medical Management Plan This plan should be completed by the student’s personal health care team and parents/guardian. Please fill out entire form. �.Ϯ�V*����n�&������5�T��oU&�z�G ; � L��[��+�NCra� Y�{� endobj Tools for Effective Diabetes Management | 61 Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes … Revised: 6/2020 Page 1 of 4 Form: 2019-011 Owner: Health Services Print Locally . Review with This section must be signed and dated by the medical practitioner. … Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardian. Route: IM/intranasal (circle one) Dose: mg Administration site: Thigh One nare Other If a glucagon dose is required, administer it immediately, call 911 (or other emergency assistance) and then Diabetes Medical Management Plan – Page 1 of 5 DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health F-43013 (Rev. ����� � ���B .��0�\� ;/��Y$�8.1�2B^l2�ZF�GXh�lV��i=�DO*e�r��(�3`�;��������x����D���=��|I=�1x��kC��0���!����!������Ѽ\�=���!$ y��}쁀!x�%8�A���H� !�{6�Pz��61���@k��{��'�'�g"J�3hӂT���tC"�p&C\�#`b�i�Bv D UŎ��e4W��%I���O�Wu��$���nW�,4�HѼ�q�dE��u-�V,Ίe/܃��1Vtt4 i�0-�v0 h�,;� Diabetes – Medical Management Plan Worksheet Treatment of severe low blood sugars: Glucagon or Baqsimi should be given if the student is unconscious, having a seizure (convulsions), or unable to swallow. 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Diabetes Medical Management Plan 2017 Page 1 of 6 4/2017 Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. Simply, download and print the PDF version available below, review each action and tick the relevant columns. Diabetes Medical Management Plan/ Florida Governor’s Diabetes Advisory Council Page 2 of 2 . This document serves as the Diabetes Medical Management Plan as specified by Georgia state law. P(쨙�➒Q��"�Mv�+���^Jl*��1�#��ϸsr"�*=�BП��@�`��y"�}]��v��\�%�1v�7� ��]�{�����L�zG&�!�e��t�� Ic2���$�T�Lէ���̘ve��0I�����淐�h! this document, please see the Diabetes Dictionary. PARENT CONSENT FOR DIABETES MEDICAL MANAGEMENT PLAN . 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This Seizure Medical Management Plan has been approved by: _____ _____ _____ Healthcare Provider Date E-mail . !F%p�>I�z�M�e~2�Y.m>����Δ� 52 Helping the Student with Diabetes Succeed Diabetes Medical Management Plan Continued Hypoglycemia (Low Blood Sugar) Usual symptoms of hypoglycemia: Treatment of hypoglycemia: Glucagon should be given if the student is unconscious, having a seizure (convulsion), or … Part B: Diabetes Medical Management Plan. Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. I have reviewed this information form and agree with the indicated information. DIABETES MANAGEMENT PLAN Diabetes NSW & ACT - 1300 136 588 Emergency Management Refer to student’s individualised ACTION PLAN for treatment in conjunction with the below details. 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Diabetes Medical Management Plan C:\Users\gutierrez.jon\Desktop\Website Documents 201718\Diabetes_ManagementPlan for School.doc Hypoglycemia Self treatment of mild lows Assistance for all lows Immediately treat with 15 gm of fast-acting carbohydrate (e.g., 4 oz juice, 3-4 glucose tabs, 4 oz regular soda, 8 oz skim milk) Important actions. Make a start once you've chosen the actions you are ready to do now. endstream endobj startxref �)��"��F�-�'�~�������d��! It should The information in … Revised: 6/2019 Page 1 of 3 Form: 2019-011 Owner: Health Services Print Locally . It b: page 9 0 obj copies should be kept in a place that can be accessed easily by the school nurse, trained . It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes … This form will assist the school health personnel in developing a nursing care plan. A few pointers for filling out a Diabetes Medical Management Plan: The form should be completed by the student’s personal health care team and parents/guardians. The Diabetes UK Management Plan protocols need to be activated and will generate a pop up alert for patients if they are pregnant, have a Kidney Disease or have a raised BP/HbA1c/Cholesterol value, and no record of a diabetes management plan in the last 6 months, no record of a eGFR or ACR test in It is the Even though resources vary widely within the Region, the primary resource in diabetes care is now recognized to be the people with diabetes themselves, supported by well trained and enthusiastic health care professionals. Diabetes Medical Management Plan Author: Division of Student Support, Academic Enrichment,and Educational Policy Subject: Diabetes Medical Management Plan Keywords: Diabetes Medical Management Plan Created Date: 7/9/2020 11:32:57 AM Authorization to Conduct Blood Glucose Testing in Location other than the Clinic The following diabetes supplies should be available to the student during school-sponsored activities: A copy of the student’s Diabetes Medical Management Plan (DMMP), Section 504 Plan, Emergency Action Plan, and Healthcare Plan Injection/insulin pump supplies and insulin with appropriate storage to prevent spoilage of insulin �6�T. 68 0 obj <> endobj �&��$�v?x�&�̀'�����h �j�2ȑ���($v ���sR�K�\��T�z��_]��B,�ݫtQ���6OƳ�Ʒ�M_��7U��B��"��j�-�g�A����bs����LΣ��(��D��������A��n����0� �R�Tkt+�(|����Ԟ#Hd8�la#Xd�0"6�xA� ����6 �E���� (Code of Virginia § 22.1-274) Parent authorization for trained school designees to administer: *Providers should complete Insulin:Carbohydrate ratio and Correction dosage under Plan B section for ALL pump users. %PDF-1.7 %���� This form will assist the school health personnel in developing a nursing care plan. *RevisedSeptember!2013!! ��Hb�W��Ti��=T[Tg&P�1j���`�"���87(l�c6P�64�5e�/}�����۸�8�x��M� Follow blood glucose monitoring plan … DIABETES(MEDICAL(MANAGEMENT(PLAN(DMMP)((For(Student(RequiringInsulinTherapy(!! I understand that in some school districts specialized health care services may be observed by unlicensed designated school personnel under the training provided by a school nurse or RN. Date of Plan: _____ Diabetes Medical Management Plan This plan should be completed by the student’s personal health care team and parents/guardian. Please fill out entire form. �.Ϯ�V*����n�&������5�T��oU&�z�G ; � L��[��+�NCra� Y�{� endobj Tools for Effective Diabetes Management | 61 Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes … Revised: 6/2020 Page 1 of 4 Form: 2019-011 Owner: Health Services Print Locally . Review with This section must be signed and dated by the medical practitioner. … Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardian. Route: IM/intranasal (circle one) Dose: mg Administration site: Thigh One nare Other If a glucagon dose is required, administer it immediately, call 911 (or other emergency assistance) and then Diabetes Medical Management Plan – Page 1 of 5 DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health F-43013 (Rev. ����� � ���B .��0�\� ;/��Y$�8.1�2B^l2�ZF�GXh�lV��i=�DO*e�r��(�3`�;��������x����D���=��|I=�1x��kC��0���!����!������Ѽ\�=���!$ y��}쁀!x�%8�A���H� !�{6�Pz��61���@k��{��'�'�g"J�3hӂT���tC"�p&C\�#`b�i�Bv D UŎ��e4W��%I���O�Wu��$���nW�,4�HѼ�q�dE��u-�V,Ίe/܃��1Vtt4 i�0-�v0 h�,;� Diabetes – Medical Management Plan Worksheet Treatment of severe low blood sugars: Glucagon or Baqsimi should be given if the student is unconscious, having a seizure (convulsions), or unable to swallow. Diabetes Medical Management Plan This plan should be completed by the student’s personal health care team and parents/guardian. 1 0 obj Hypoglycaemia (Hypo) A hypo is a low blood glucose level (BGL), occurring when the BGL is less than . f`�/�x�B�S�\h���V�s�/3m��d�>7�z�I?�ڲ��s 1�,�27�'"�{�V�8�vO��q� �&��^�w�[l�or��(!V%� Management Plan To Of state which regulates the of to diabetic l, law designee any may of In to a Medlcal in the Health Office, The physician is &legating of to A delegate to the in of fu of developed by This to child in I (Parent) 2 - 5 (Dcctorj Diabet« & 8 (Sign 4 Page 9 & I & highlighted g with This date plan for child. Virginia Diabetes Medical Management Plan (DMMP) Adapted from the National Diabetes Education Program DMMP (2016) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. Plan B: Multiple Daily Injections 1. endstream endobj 69 0 obj <>>>/Lang(en)/MarkInfo<>/Metadata 31 0 R/Pages 66 0 R/Type/Catalog/ViewerPreferences<>>> endobj 70 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/TrimBox[0 0 612 792]/Type/Page>> endobj 71 0 obj <>stream Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff and . It should be reviewed with relevant school staff and copies should be kept in a place that can be accessed easily by the school nurse, trained diabetes personnel, [+l�8���v���y'�E�y�)��ƷQ'ڗ�&b&}�3��#�'�o��f��2��9-�8�>� q{�� }d�Zb�c��dae�����3p�-3��&C�KJ-G� hެY�nG��y��0��U}�oDZa���@K�L������9�C��Œ�gb�j��V;���Erx�ȇ�I�t�S�������;�R� �@��]L�o 113 0 obj <>stream 2�.֐l��}���2�K9殟LW�Ӯ$��q�����qw6]�f��w�_�����p������?�����n��6����������?�_g��\��x=]�&'S���f��="ۄQ�{�h3����������r=__��|���W�����ӫϳ���o_�.f�ܹ���?j����ןf��/kF'�g�˫���bz��t���r}pp�g��'�O�1q�`�L/��ﮗ��i�ay����/fҕL�ڋ_��������� ��WW�S�|�^��'_6��OM����h=]�O�/�3j=����14�p,u_ο������-i��_z�CX������ Diabetes Medical Management Plan . �� �@����l1 �9�q) �S�+�.����S@�a6S�yU�J.\�2و�����LĽT��Pd`�+�D� D The most important action in this plan is … x�͝Yo�H�� �;�Q��E6���8��,��ٍ�y,�MG�X���[GSv,�V��*�"�}���]l���W��Zc����imq�����X����={c��8:��3pLU�"T�/,��G�����5�� We also have a printable version of the action plan. <>stream %���� DIABETES CARE FOR SCHOOL – Continuous Glucose Monitor Appendix Continuous Glucose Monitor (CGM) is an external device that measures glucose in the interstitial fluid under the skin and transmits blood glucose readings to a secondary receiver. Diabetes Medical Management Plan 2017 Page 1 of 6 4/2017 Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. Simply, download and print the PDF version available below, review each action and tick the relevant columns. Diabetes Medical Management Plan/ Florida Governor’s Diabetes Advisory Council Page 2 of 2 . This document serves as the Diabetes Medical Management Plan as specified by Georgia state law. P(쨙�➒Q��"�Mv�+���^Jl*��1�#��ϸsr"�*=�BП��@�`��y"�}]��v��\�%�1v�7� ��]�{�����L�zG&�!�e��t�� Ic2���$�T�Lէ���̘ve��0I�����淐�h! this document, please see the Diabetes Dictionary. PARENT CONSENT FOR DIABETES MEDICAL MANAGEMENT PLAN . 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management of diabetes and on how to educate people with diabetes is one major aspect that requires strengthening. 06/16) (608) 261-6855 DIABETES MEDICAL MANAGEMENT PLAN The student’s healthcare provider and parents/guardians should complete this form. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel. NV�ѷ����������|�'��z���u���b�����{�������sDŽ�; ��4�vR(~QU���Q�����l��c�r��Ve�o�3G�w��xq5�d����Ϧ ;��OS�W�kM��6��-�"�f�j'��L����#�zu����d�ڶ4.W!~WB`ǖ�6>�U�W��gJ��e�U(�eF*K�@����k�[��?�|�8�����rQ\]/Ϡ�����T���l(M�&i9�8nq������kpB��i���*o*�ձ�u��׾T�L}��a����=���G���)ic�Cm�{��M>Nv��;�/س��c|;���vr9�蝡!�����z������i˶.�)�/�o*�45~���i%N}T ΍-��j�W��}7y5��'9!�����8ޑ_�҆�T�tU�m�EK�?���Xh)��_?Mm.��}���L��5�x7�P ����>�| �5��$x�ז�C��)�)�.�…W5S�`y>�BgШը�Mi�/�b'�����'m�Ȯ}��5�ޔ��tq����MM��6ݗ�:���cv�~���Hj�J. Title: Information Sheet for the School Management of Diabetes Mellitus Subject: Diabetes Prevention & Control Program Created Date: <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/MediaBox[0 0 612 792]/Contents 9 0 R/Group<>/Tabs/S/Parent 10 0 R>> I understand that the information contained in this plan will be shared with school staff on a need- to-know basis. I give permission for school personnel to contact my child’s diabetes provider for guidance and recommendations. �H�C4\HjA@t��a'�lj�|a�6��xK�3�����k��WDڈ�$�U����`�`d�ϥ���Ը���<8�E�Pע��7��5�GԳ(�c4ZD~S���]����x�1�y��*������'�� h�b```���� ce`a�XpJ��a���ta]F~9��y��� ST. JOHNS COUNTY SCHOOL DISTRICT HEALTH SERVICES ! FOR DIABETES MEDICAL MANAGEMENT PLAN My signature below provides authorization for this Diabetes Medical Management Plan. FOR DIABETES MEDICAL MANAGEMENT PLAN My signature below provides authorization for this Diabetes Medical Management Plan. Review with relevant school staff and ask that copies be kept in a place easily accessed by other school personnel. This Seizure Medical Management Plan has been approved by: _____ _____ _____ Healthcare Provider Date E-mail . !F%p�>I�z�M�e~2�Y.m>����Δ� 52 Helping the Student with Diabetes Succeed Diabetes Medical Management Plan Continued Hypoglycemia (Low Blood Sugar) Usual symptoms of hypoglycemia: Treatment of hypoglycemia: Glucagon should be given if the student is unconscious, having a seizure (convulsion), or … Part B: Diabetes Medical Management Plan. Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. I have reviewed this information form and agree with the indicated information. DIABETES MANAGEMENT PLAN Diabetes NSW & ACT - 1300 136 588 Emergency Management Refer to student’s individualised ACTION PLAN for treatment in conjunction with the below details. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel. I have reviewed this medical management plan and agree with the indicated instructions. We (I), the undersigned, the parent(s)/guardian(s) of the above named child, request that this Diabetes Medical Management Plan, and any modification thereto, be implemented while our (my) child is at school or attending a school-related event on or off campus. Date of Plan: _____ Diabetes Medical Management Plan This plan should be completed by the student’s personal health care team and parents/guardian. Child will receive a fixed dose of _____ long-acting insulin at _____ Yes No 2. %PDF-1.5 the diabetes care tasks for my child as outlined in my child’s Diabetes Medical Management Plan as ordered by the prescribing health care provider. Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardian. This section must be completed by the student’s physician or advanced practice nurse and provides the medical “orders” for the student’s care. Diabetes Medical Management Plan . I understand that in some school districts specialized health care services may be observed by unlicensed designated school personnel under the training provided by a school nurse or RN. %%EOF outlined in this Diabetes Medical Management Plan and/or 504 Medical Plan and for my child’s healthcare provider to share information with the school for completion of this plan. �r � �f+�J U �.H�Dx��`�V "H؁X̾@�+H�o�@B�:�`�$�Y�.��e`�!�q�[� �=] This!plan!should!be!completed!by!the!student’s!parent(s)/guardian(s)!and!the!diabetes! 0 I have reviewed this medical management plan and agree with the indicated instructions. Diabetes Medical Management Plan C:\Users\gutierrez.jon\Desktop\Website Documents 201718\Diabetes_ManagementPlan for School.doc Hypoglycemia Self treatment of mild lows Assistance for all lows Immediately treat with 15 gm of fast-acting carbohydrate (e.g., 4 oz juice, 3-4 glucose tabs, 4 oz regular soda, 8 oz skim milk) Important actions. Make a start once you've chosen the actions you are ready to do now. endstream endobj startxref �)��"��F�-�'�~�������d��! It should The information in … Revised: 6/2019 Page 1 of 3 Form: 2019-011 Owner: Health Services Print Locally . It b: page 9 0 obj copies should be kept in a place that can be accessed easily by the school nurse, trained . It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes … This form will assist the school health personnel in developing a nursing care plan. A few pointers for filling out a Diabetes Medical Management Plan: The form should be completed by the student’s personal health care team and parents/guardians. The Diabetes UK Management Plan protocols need to be activated and will generate a pop up alert for patients if they are pregnant, have a Kidney Disease or have a raised BP/HbA1c/Cholesterol value, and no record of a diabetes management plan in the last 6 months, no record of a eGFR or ACR test in It is the Even though resources vary widely within the Region, the primary resource in diabetes care is now recognized to be the people with diabetes themselves, supported by well trained and enthusiastic health care professionals. Diabetes Medical Management Plan Author: Division of Student Support, Academic Enrichment,and Educational Policy Subject: Diabetes Medical Management Plan Keywords: Diabetes Medical Management Plan Created Date: 7/9/2020 11:32:57 AM Authorization to Conduct Blood Glucose Testing in Location other than the Clinic The following diabetes supplies should be available to the student during school-sponsored activities: A copy of the student’s Diabetes Medical Management Plan (DMMP), Section 504 Plan, Emergency Action Plan, and Healthcare Plan Injection/insulin pump supplies and insulin with appropriate storage to prevent spoilage of insulin �6�T. 68 0 obj <> endobj �&��$�v?x�&�̀'�����h �j�2ȑ���($v ���sR�K�\��T�z��_]��B,�ݫtQ���6OƳ�Ʒ�M_��7U��B��"��j�-�g�A����bs����LΣ��(��D��������A��n����0� �R�Tkt+�(|����Ԟ#Hd8�la#Xd�0"6�xA� ����6 �E���� (Code of Virginia § 22.1-274) Parent authorization for trained school designees to administer: *Providers should complete Insulin:Carbohydrate ratio and Correction dosage under Plan B section for ALL pump users. %PDF-1.7 %���� This form will assist the school health personnel in developing a nursing care plan. *RevisedSeptember!2013!! ��Hb�W��Ti��=T[Tg&P�1j���`�"���87(l�c6P�64�5e�/}�����۸�8�x��M� Follow blood glucose monitoring plan … DIABETES(MEDICAL(MANAGEMENT(PLAN(DMMP)((For(Student(RequiringInsulinTherapy(!! I understand that in some school districts specialized health care services may be observed by unlicensed designated school personnel under the training provided by a school nurse or RN. Date of Plan: _____ Diabetes Medical Management Plan This plan should be completed by the student’s personal health care team and parents/guardian. Please fill out entire form. �.Ϯ�V*����n�&������5�T��oU&�z�G ; � L��[��+�NCra� Y�{� endobj Tools for Effective Diabetes Management | 61 Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes … Revised: 6/2020 Page 1 of 4 Form: 2019-011 Owner: Health Services Print Locally . Review with This section must be signed and dated by the medical practitioner. … Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardian. Route: IM/intranasal (circle one) Dose: mg Administration site: Thigh One nare Other If a glucagon dose is required, administer it immediately, call 911 (or other emergency assistance) and then Diabetes Medical Management Plan – Page 1 of 5 DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health F-43013 (Rev. ����� � ���B .��0�\� ;/��Y$�8.1�2B^l2�ZF�GXh�lV��i=�DO*e�r��(�3`�;��������x����D���=��|I=�1x��kC��0���!����!������Ѽ\�=���!$ y��}쁀!x�%8�A���H� !�{6�Pz��61���@k��{��'�'�g"J�3hӂT���tC"�p&C\�#`b�i�Bv D UŎ��e4W��%I���O�Wu��$���nW�,4�HѼ�q�dE��u-�V,Ίe/܃��1Vtt4 i�0-�v0 h�,;� Diabetes – Medical Management Plan Worksheet Treatment of severe low blood sugars: Glucagon or Baqsimi should be given if the student is unconscious, having a seizure (convulsions), or unable to swallow. Diabetes Medical Management Plan This plan should be completed by the student’s personal health care team and parents/guardian. 1 0 obj Hypoglycaemia (Hypo) A hypo is a low blood glucose level (BGL), occurring when the BGL is less than . f`�/�x�B�S�\h���V�s�/3m��d�>7�z�I?�ڲ��s 1�,�27�'"�{�V�8�vO��q� �&��^�w�[l�or��(!V%� Management Plan To Of state which regulates the of to diabetic l, law designee any may of In to a Medlcal in the Health Office, The physician is &legating of to A delegate to the in of fu of developed by This to child in I (Parent) 2 - 5 (Dcctorj Diabet« & 8 (Sign 4 Page 9 & I & highlighted g with This date plan for child. Virginia Diabetes Medical Management Plan (DMMP) Adapted from the National Diabetes Education Program DMMP (2016) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. Plan B: Multiple Daily Injections 1. endstream endobj 69 0 obj <>>>/Lang(en)/MarkInfo<>/Metadata 31 0 R/Pages 66 0 R/Type/Catalog/ViewerPreferences<>>> endobj 70 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/TrimBox[0 0 612 792]/Type/Page>> endobj 71 0 obj <>stream Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff and . It should be reviewed with relevant school staff and copies should be kept in a place that can be accessed easily by the school nurse, trained diabetes personnel, [+l�8���v���y'�E�y�)��ƷQ'ڗ�&b&}�3��#�'�o��f��2��9-�8�>� q{�� }d�Zb�c��dae�����3p�-3��&C�KJ-G� hެY�nG��y��0��U}�oDZa���@K�L������9�C��Œ�gb�j��V;���Erx�ȇ�I�t�S�������;�R� �@��]L�o 113 0 obj <>stream 2�.֐l��}���2�K9殟LW�Ӯ$��q�����qw6]�f��w�_�����p������?�����n��6����������?�_g��\��x=]�&'S���f��="ۄQ�{�h3����������r=__��|���W�����ӫϳ���o_�.f�ܹ���?j����ןf��/kF'�g�˫���bz��t���r}pp�g��'�O�1q�`�L/��ﮗ��i�ay����/fҕL�ڋ_��������� ��WW�S�|�^��'_6��OM����h=]�O�/�3j=����14�p,u_ο������-i��_z�CX������ Diabetes Medical Management Plan . �� �@����l1 �9�q) �S�+�.����S@�a6S�yU�J.\�2و�����LĽT��Pd`�+�D� D The most important action in this plan is … x�͝Yo�H�� �;�Q��E6���8��,��ٍ�y,�MG�X���[GSv,�V��*�"�}���]l���W��Zc����imq�����X����={c��8:��3pLU�"T�/,��G�����5�� We also have a printable version of the action plan. <>stream %���� DIABETES CARE FOR SCHOOL – Continuous Glucose Monitor Appendix Continuous Glucose Monitor (CGM) is an external device that measures glucose in the interstitial fluid under the skin and transmits blood glucose readings to a secondary receiver. Diabetes Medical Management Plan 2017 Page 1 of 6 4/2017 Diabetes Medical Management Plan (DMMP) This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. Simply, download and print the PDF version available below, review each action and tick the relevant columns. Diabetes Medical Management Plan/ Florida Governor’s Diabetes Advisory Council Page 2 of 2 . This document serves as the Diabetes Medical Management Plan as specified by Georgia state law. P(쨙�➒Q��"�Mv�+���^Jl*��1�#��ϸsr"�*=�BП��@�`��y"�}]��v��\�%�1v�7� ��]�{�����L�zG&�!�e��t�� Ic2���$�T�Lէ���̘ve��0I�����淐�h! this document, please see the Diabetes Dictionary. PARENT CONSENT FOR DIABETES MEDICAL MANAGEMENT PLAN . 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