Hampton Roads Regional Schools Diabetes Medical Management Plan Forms

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1 Hamptn Rads Reginal Schls Diabetes Medical Management Plan Frms Develped by the Hamptn Rads Schl Nurse Managers The Virginia Schl Diabetes Management Prtcl is a guide t be used t prmte & ensure excellence, safety and supprt fr children with diabetes in ur schls. This prtcl is a cllabrative effrt between parents/guardians, students, medical prviders and schl persnnel. Parents/Guardians cmplete Part 1 (bth sides) medical histry and cntact infrmatin, includes: Parent authrizatin fr trained schl designees. Part 2 must be cmpleted by yur medical prvider and Part 3 if applicable. Part 4, if applicable, must be cmpleted by the medical prvider, parent and schl nurse. Return all apprpriate frms t the Schl Nurse. Please cntact the Schl Nurse t review the entire prtcl and develp apprpriate measures. Medical review has been prvided by a multispecialty grup f Pediatric Endcrinlgists and Certified Diabetes Educatrs frm: Animas Crpratin Carilin Health System, Ranke, VA Children s Hspital f The King s Daughters, Nrflk, VA Children s Natinal Medical Center, Washingtn, DC Eastern Virginia Medical Schl, Nrflk, VA Inva Diabetes Center, Nrthern Virginia Prtsmuth Naval Hspital, Prtsmuth, VA University f Virginia, Charlttesville, VA Virginia Cmmnwealth University Health System/Medical Cllege f VA, Richmnd, VA Additinal review has been prvided by: The American Diabetes Assciatin (natinal ffice and lcal affiliates) Virginia Department f Educatin Virginia Department f Health *Octber 2015 Annual Flu shts fr students* * N ut f pcket cst t families * Students with Newprt a chrnic health News prblem Public such Schls as diabetes must have a signed request frm yur dctr. Please discuss this with yur dctr. Student s Name: Grade: Schl:

2 I. Virginia Schl Diabetes Medical Management Plan Part 1. Parent/Guardian Infrmatin includes Parent Authrizatins fr Trained Schl Designees - included This frm is distributed by the schl nurse/clinic and is t be cmpleted by the parent r guardian. The infrmatin in this frm prvides helpful infrmatin fr cmpleting the Individualized Health Plan. This frm is required by the State f Virginia Bard f Educatin as required by law t determine parent/guardian permissin r denial f permissin fr administratin f insulin and/r glucagn by trained unlicensed persnnel. This frm des nt require any invlvement frm the healthcare prvider s ffice. Part 2. Physician Orders and Authrizatins btain frm yur physician Children with diabetes receiving care at Children s Hspital f The King s Daughters, Prtsmuth Naval Hspital and the Medical Cllege f Virginia have agreed t use the frms included in this dcument. They may cmplete the frms electrnically, in writing r a cmbinatin f bth. Parents/guardians shuld request r btain these cmpleted frms frm their physician and are required t sign these frms t authrize cmmunicatin between the healthcare prvider s ffice and the schl. Schl frms will nt autmatically be sent t the schl withut the caregivers request. The frms shuld then be brught t the schl by the child s caregiver. If anther physician s ffice prefers t use his/her wn Diabetes Medical Management Plan it must include all f the elements in this frm (cpies f these frm may be shared electrnically r by printing t any healthcare prvider r family). Please nte that physician authrizatin fr treatment by trained schl designees must be included in the Diabetes Medical Management Plan r a separate frm must be prvided. Healthcare prviders are aware that children may be restricted frm attending schl if these frms are nt prvided t the schl, but cannt be held respnsible if the frms are nt delivered t the schl by the caregiver. Prviders may make changes t these rders during the schl year and are permitted t send nly the applicable page requiring changes (the entire rder set is nt required and new caregiver signatures are nt required with changes). New frms are required n an annual basis. Part 3. Plan Supplement fr Student Wearing Insulin Pump btain frm yur dctr If the child wears an insulin pump this supplemental frm shuld be cmpleted by the physician and caregiver. Prtins f this frm will be cmpleted by the parent/guardian after the healthcare prvider initiates the sectins requiring rders. This frm has been develped t help prvide infrmatin regarding the child s prficiency in perating their insulin pump and t prvide infrmatin n areas f peratin where they will require assistance r supervisin. Parents/caregivers are required t prvide adequate instructin, manuals and supplies t supprt pump therapy use in the schl. Part 4. Permissin t Self-Carry btain frm yur dctr r the schl nurse If a child is ging t carry and self administer insulin and perfrm bld sugar checks in the classrm; an Authrizatin t Carry and Self-Administer Medicatin Frm must be cmpleted by the physician, schl nurse and the parent. As explained n the frm, the schl has the ptin t revke this privilege if adherence t schl rules r guidelines is nt demnstrated by the student.

3 III. Hamptn Rads Reginal Schl Diabetes Medical Management Frms Student Schl Effective Date Date f Birth Grade Hmerm Teacher Dear Parent/Guardian: 1. Part 1- Medical histry and cntact infrmatin. T be cmpleted by parent/guardian. Includes: Parent authrizatin fr trained schl designees. T be cmpleted by parent/guardian. 2. Part 2*- Have yur child s physician cmplete unless the physician s ffice prefers t use his/her wn Diabetes Medical Management Plan. Please nte that physician authrizatin fr treatment by trained schl designees must be included in the Diabetes Medical Management Plan r a separate frm must be prvided. 3. Part 3*- Have the physician/diabetes educatr/caregiver cmplete if yur child wears an insulin pump. 4. Part 4- If yur child is ging t carry and self administer insulin and perfrm bld sugar checks in the classrm; an Authrizatin t Carry and Self-Administer Medicatin Frm must be cmpleted by the physician, schl nurse and the parent. *Other Diabetic Medical Management Plans may be used fr Parts 2 & 3 as lng as all cmpnents are represented. Return cmpleted frms t the schl nurse as quickly as pssible. Thank yu fr yur cperatin. Schl nurse Phne Date Please nte: during the schl year, in rder t change yur child s diabetes care at schl, an updated physician s rder must be submitted t the schl nurse. Part 1: Parent/Guardian t cmplete: Cntact Infrmatin: Parent/Guardian #1: Address: Telephne-Hme: Wrk: Cell: Parent/Guardian #2: Address: Telephne-Hme: Wrk: Cell: Other emergency cntact: Address: Relatinship: Telephne-Hme: Wrk: Cell: Physician managing diabetes: Address: Main Office # Fax # Emergency Phne # Nurse/Diabetes Educatr Wrk # Diabetes Questins Parent/Guardian Respnse (check apprpriate bxes and cmplete blanks) Diagnsis infrmatin At what age? Type f diabetes? Hw ften is child seen by this physician? Include date last seen. Nutritinal needs Snack AM PM Prir t Exercise/Activity Only in case f lw bld glucse Student may determine if CHO cunting

4 Child s mst cmmn signs f lw bld glucse Hw ften des child experience lw bld glucse and hw severe? Episde(s) f ketacidsis Field trips Serius illness, injuries r hspitalizatins this past year List any ther medicatins currently being taken Allergies (include fds, medicatins, etc): In the event f a class party may eat the treat (include insulin cverage if indicated in medical rders) student able t determine whether t eat the treat replace with parent supplied treat may NOT eat the treat ther trembling tingling lss f crdinatin dizziness mist skin/sweating slurred speech heart punding hunger cnfusin weakness fatigue seizure pale skin headache uncnsciusness change in md r behavir ther Mild nce a day nce a week nce a mnth Indicate date(s) f last mild episde(s) Severe (i.e. uncnscius, unable t swallw, seizure, r needed Glucagn) Include date(s) f recent episde(s) Include date(s) f recent episde(s) Parent/guardian will accmpany child during field trips? YES NO Yes, if available Date(s) and describe Other cncerns and cmments I give permissin t the schl nurse and designated schl persnnel*, wh have been trained and are under the supervisin f the schl nurse t perfrm and carry ut the diabetes care tasks as utlined in my child s Diabetes Medical Management Plan as rdered by the physician. I give permissin t the designated schl persnnel, wh have been trained t perfrm the fllwing diabetes care tasks fr my child. (Cde f Virginia ). Insulin Administratin YES NO Glucagn Administratin YES NO I understand that I am t prvide all supplies t the schl necessary fr the treatment f my child s diabetes. I als cnsent t the release f infrmatin cntained in the Diabetes Medical Management Plan t staff members and ther adults wh have custdial care f my child and wh may need t knw this infrmatin t maintain my child s health and safety. I als give permissin t cntact the abve named physician and members f the diabetes management team regarding my child s diabetes shuld the need arise. Parent/Guardian Name Date Parent/Guardian Signature Schl Nurse s Name Date Schl Nurse s Signature *Nte: If at any time yu wuld like t have the names f the designated schl persnnel that have been trained, please cntact the schl nurse. Names and training recrds are kept in the schl clinic.

5 II. Respnsibilities fr Implementatin A. Parent/Guardian Respnsibilities 1. Infrm the schl nurse/schl administratr that yur child has diabetes when the student enrlls in schl r is newly diagnsed. 2. Prvide accurate emergency cntact infrmatin and update as necessary. 3. Prvide the Diabetes Medical Management Plan (DMMP), signed by yur child s medical prvider and yurself t the schl nurse. This plan must be renewed prir t the beginning f each schl year. 4. Infrm schl nurse/schl administratr f any changes in the student s health status and/r DMMP. 5. Prvide all supplies and equipment necessary fr implementing yur child s DMMP. Replenish supplies as needed (within 48 hurs f ntificatin). 6. Infrm the schl nurse and ther apprpriate schl staff when the student plans t participate in schl-spnsred activities. 7. Authrize trained unlicensed schl persnnel t administer insulin and glucagn in the absence f a registered nurse. 8. Teach yur child t: a. Understand age-apprpriate diabetic care (refer t Student Respnsibilities). b. Cmmunicate clearly t adults in authrity that he/she has diabetes and is nt feeling well. c. Infrm yu abut his/her diabetes management during the schl day. d. Wear a medical alert ID at all times. 9. Review Checklist fr Parents (Appendix A).

6 B. Student Respnsibilities 1. Learn age-apprpriate diabetic care 2. Knw the fllwing: a. Wh t cntact and what t d when having a lw r high bld sugar reactin b. What the written schl plans says t help manage yur diabetes c. When yu shuld check bld glucse levels, give insulin, have a snack, and eat breakfast/ lunch d. Where the diabetes supplies are stred, if yu d nt carry them, and wh t cntact when yu need t use them 3. Take charge f yur diabetes care at schl as the DMMP allws. This may include: a. Mnitring and recrding bld glucse levels b. Calculating accurate insulin dses (if n pre-meal glucse checked, nly cver carbs) c. Self-administratin f insulin/medicatins d. Prper dispsal f needles, lancets, and ther supplies prperly e. Eating meals and snacks as prescribed f. Treating hypglycemia and hyperglycemia (lw & high bld sugar) g. Carrying and using diabetes equipment and supplies as directed 4. Cperate with schl and healthcare persnnel wh are assisting yu with & supervising yur diabetes care.

7 C. Checklist fr Parents/Schl Checklist DIABETES SCHOOL CHECKLIST Read Parental Respnsibilities Read and discuss Student with Diabetes Respnsibilities with student Have the student s Dctr cmplete the Diabetic Medical Management Plan, Parts I, II, and if necessary Part III (Pump Management) Discuss specific care f yur child with the teachers, schl nurse, bus driver, caches and ther staff wh will be invlved. Cmplete Part 1 f the Schl Diabetes Medical Management frms and return t schl clinic. (Appendix L) Make sure yur child understands the details f wh will help him/her with testing, shts and treatment f high r lw bld sugars at schl and where supplies will be kept. Supplies shuld be kept in a place where they are always available if needed. Make arrangements fr the schl t send hme bld sugar recrds weekly (r fax t MD ffice). Keep current phne numbers where yu can be reached. Cmplete a medical release giving the schl written permissin t cntact the child s healthcare prvider in the event f an emergency. Cmplete release fr administratin f glucagn by trained, unlicensed persnnel. Cllect equipment / supplies fr schl including the fllwing: Bx with the child s name t stre these items (yu may need ne fr meds and ne fr fd). Medical Identificatin Meter Strips Lancets & Device Insulin Syringes r pens & pen needles Alchl wipes Glucagn Kit with instructins Ketne testing strips Sharps cntainer Lg sheets fr bld sugars Check regularly t make sure schl has all necessary supplies (suggest mnthly) Pump supplies Batteries fr meter &/r pump Fd/Drinks fr treating Lw Bld Sugar 15 gm CHO Juice cans r bxes Glucse tabs Instant glucse r cake decrating gel Fruit-Rll Ups Dried Fruit, raisins r ther snacks Crackers (± peanut butter and/r cheese)

8 D. Supply List fr Insulin Pumps Supply List fr Insulin Pumps Bld glucse mnitring device, test strips, lancets Sharps Cntainer Extra meter battery Extra pump battery Insulin and syringes Extra infusin sets, reservirs/cartridges and insertin device (r extra Pds) Alchl pads Dressing and tape (r ther adhesive) Glucse tablets/instant glucse Glucagn emergency kit Ketne test strips

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