ST. MARY’S COUNTY PUBLIC SCHOOLS
Department of Student Services/St. Mary’s County Health Department
PARENTAL AND PHYSICIAN DIABETES MEDICATION/MEDICAL TREATMENT AUTHORIZATION
This order is valid only for the Current School Year: _______ (including summer session)
Glucagon Expiration Date:
Student:
D.O.B.:
School:
Grade:
Contact Information
Parent(s)/Legal Guardian(s):
Parent(s)/Legal Guardian(s):
Other Emergency Contact:
Home Phone:
Home Phone:
Work:
Work:
Insulin Orders (Complete only if insulin is needed at school):
1. Insulin Administration Via:
 Syringe and vial
 Insulin pen
 Other
 Insulin pump
Type of pump:
Basal rates:
2. Insulin Before Lunch/Meals:
Name of Insulin:
 Routine lunchtime dose:
 Per sliding scale as follows:
Meals
Blood Glucose
Blood Glucose
Blood Glucose
Blood Glucose
Blood Glucose
Blood Glucose
Blood Glucose
to
to
to
to
to
to
to
give
give
give
give
give
give
give
units
units
units
units
units
units
units
Blood Glucose
Blood Glucose
Blood Glucose
Blood Glucose
Blood Glucose
Blood Glucose
Blood Glucose
Cell/Pager:
Cell/Pager:
to
to
to
to
to
to
to
 Calculated insulin dose (add carbohydrate coverage and correction dose for total insulin dose):
Carbohydrate Coverage:
Insulin to carbohydrate ratio
Give
# unit(s) insulin per
gms carbohydrate.
Correction:
Give
# unit(s) insulin per
mg/dl of glucose above
mg/dl
Subtract
# units for every
mg/dl of glucose below
mg/dl
 Insulin may be given after lunch if
3. Other times insulin may be given:
 Snack:
 Snack
Dose:
 Calculated as above.
 Blood Glucose
 Ketones:
If ketones are
Give/Add:
unit(s)
If ketones are
Give/Add:
unit(s)
Blood Glucose Monitoring:
Target range for blood glucose monitoring at school:
 Before snacks
 2 hours or
 Before meals
 2 hours or
 As needed for symptoms of hypo/hyperglycemia
 With signs and symptoms of illness
 Other times:
Hypoglycemia – blood glucose less than
 Self treatment for mild lows.
 Provide extra protein and carbohydrate snack after treating low if next
meal/snack greater than
minutes away
 Suspend pump for severe hypoglycemia for
minutes.
give
give
give
give
give
give
give
units
units
units
units
units
units
units
Give:
units
units
hours after lunch
hours after a correction base
 Give
grams of fast-acting carbohydrate according to care
plan. Recheck BG in 10 – 15 minutes. Repeat treatment if
BG less than
mg/dl
If student is unconscious, having a seizure, or unable to swallow, presume student is having a low blood sugar and:
Call 911, notify parent(s)/legal guardian(s)
 Glucagon injection (1 mg in 1 cc)
mg, subcutaneously or intramuscular (M)
 Other
 OK to use glucose gel inside cheek, if unconscious, seizing.
PS 132 - 07/2013 - Parental/Physician Diabetes Medication/Medical Treatment Authorization - page 1 of 2 pages
PARENTAL AND PHYSICIAN DIABETES MEDICATION/MEDICAL TREATMENT AUTHORIZATION (CONTINUED)
Student:
Hyperglycemia – blood glucose greater than
 Check urine ketones, follow care plan, administer insulin as per orders.
 For pumps, insulin may be given by syringe or pen if needed.
 Encourage sugar free fluids, at least
ounces per
.
 Other:
 If student complains of nausea, vomiting, or abdominal pain; check urine ketones and check insulin administration orders.
* Transport to local Emergency Room may be needed with vomiting and large ketones.
Meal Plans
 AM snack, time:
 PM snack time:
 Avoid snack if blood glucose greater than
 Lunch:
 Extra food allowed:
 Parent(s)’/Legal Guardian(s)’ directions;
 Student’s direction
Exercise (check and/or complete all that apply)
Fast-acting carbohydrate source must be available before, during, and after all exercise.
 with student
If most recent blood glucose is less than
, exercise can occur when blood glucose is corrected and above
 Eat
grams of carbohydrate
 Before
 Every 30 minutes during
 Avoid exercise when blood glucose is greater than
or ketones are
mg/dl.
 With teacher
.
 After vigorous exercise
Bus Transportation
 Blood glucose monitoring not required prior to boarding bus
 Check blood glucose 15 minutes prior to boarding bus
 Allow student to eat on bus if having symptoms of low blood glucose
 Provide care as follows:
Health Care Provider Assessment
Student can self-perform the following procedures (school nurse must verify competency):
 Blood glucose monitoring
 Measuring insulin
 Injecting insulin
 Independently operating insulin pump
 Other:
Disaster Plan (if needed for lockdown, 24 hr shelter in place):
 Follow insulin orders as on Management Form
 Additional insulin orders as follows:
 Determining insulin dose
 Administer long acting insulin as follows:
 Other:
Other Instructions:
Health Care Provider Authorization for Management of Diabetes in School
My signature below provides authorization for the above written orders. This authorization is for a maximum of one school year. If changes are
indicated, I will provide written authorization, which may be faxed.
Health Care Provider Name:
Signature:
Address:
Phone:
Fax:
(original or stamped signature)
City:
Zip:
Date:
Use for Prescriber’s Address Stamp
Parent(s)/Legal Guardian(s) Consent for Management of Diabetes at School
I/We request designated school personnel to administer the medication and treatment orders as prescribed above. I agree:
1. To provide the necessary supplies and equipment
2. To notify the school nurse if there is a change in the student’s diabetes management or health care provider.
3. I/We further understand that any school employee who administers any medication or treatment procedure to my/our child, in accordance with written
instructions from the prescriber and St. Mary’s County Public Schools, shall not be liable for damages as a result of an adverse reaction suffered by my
child due to the administration of the drug or treatment procedure.
I authorize the school nurse to communicate with the health care provider as necessary.
Parent(s)’/Legal Guardian(s)’ Signature:
Order reviewed and signed by the school RN:
Date:
Date:
PS 132 - 07/2013 - Parental/Physician Diabetes Medication/Medical Treatment Authorization - page 2 of 2 pages