Diabetes Medical Management Plan and Glucagon Administration Log

School health form for documenting a student's diabetes care orders, blood-glucose monitoring, and glucagon administration.

Plan Overview and Consent

• Student name
• Student ID
• School name
• Grade level
• Form purpose
• Parent/guardian consent on file for school diabetes care
• Primary care team contact
  Enter only the contact details needed for care coordination.

Diabetes Care Orders

• Diabetes type
• Blood-glucose monitoring frequency at school
• Target blood-glucose range
• Low blood-glucose threshold requiring treatment
  Enter the numeric threshold from the care plan.
• High blood-glucose threshold requiring action
  Enter the numeric threshold from the care plan.
• Carbohydrate treatment instructions
  Document the minimum necessary treatment guidance for low blood glucose.
• Insulin administration authorized at school
• Insulin instructions

Blood-Glucose Monitoring Log

• Date of check
• Time of check
• Reason for check
• Blood-glucose value
  Enter the measured value from the meter or continuous glucose monitoring review.
• Units
• Symptoms observed
• Action taken
  Document the minimum necessary intervention, such as carbohydrate treatment, recheck, parent/guardian notification, or EMS activation.

Glucagon Administration Event

• Date of glucagon administration
• Time of glucagon administration
• Location of event
• Reason glucagon was given
• Glucagon product used
• Dose administered
• Response to glucagon
  Document observed response, recheck results, and any follow-up actions.
• Emergency medical services called

Notifications, Follow-Up, and Sign-Off

• Parent/guardian notified
• Notification time
• Follow-up needed
• Staff name
• Staff role
• Staff signature