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Microsoft word - diabetic order form.doc


HEALTH CARE PROVIDER ORDERS FOR STUDENTS WITH DIABETES IN WASHINGTON STATE SCHOOLS
STUDENT’SNAME
____________________________Student’sbirthdate___/___/___School_____________Grade___
Emergency numbers for parents (phone) ____-_____-_____ (Cell contact 2) ____-_____-_____ (Cell) ____-_____-____
Doctor’s phone number_____-_____-______ Other contacts________________________________, _____-_____-______
HYPOGLYCEMIA (fill in individualized instructions on line or use those in parenthesis)
Unconscious--___________________________________________(phone 911) (Other orders)___________________
Blood sugar < 60 and symptomatic _______________________(juice, pop, candy) _______________________________
Blood sugar < 100 and symptomatic _______________________(crackers/cheese) _______________________________
Blood sugar < 80 and asymptomatic ______________________(feed partial meal) _______________________________
Blood sugar > 100 and symptomatic _______________________(feed partial meal)
Blood sugar at which parent should be notified–low ____________ high ___________
BLOOD SUGAR AND INSULIN DOSAGE prior to lunch (R is regular and H is lis-pro,) _____________ any other insulin requested
Blood sugar < 100
____________ units R - H - other __________________ (see hypoglycemia above) ____________ units R - H - other __________________ ____________ units R - H - other __________________ ____________ units R - H - other __________________ ____________ units R - H - other __________________ (check ketones) ____________ units R - H - other __________________ (check ketones) ____________ units R - H - other __________________ (check ketones) ____________ units R - H - other __________________ (check ketones)
• Licensed medical personnel allowed to give _____ units (minimum) of insulin to _____ units (maximum) of R, H, other
_________ insulin after consultation with the parent/guardian.
• Other insulin instructions (i.e., CHO counting):______________________________________________________
• If urine ketones (trace, small, moderate, large) call parents (circle one or more)

DISASTER INSULIN DOSAGE-
in case of disaster how much insulin should be given? Recommend 80% of usual dose.
A.M.
units R - H - other _______________ units Lente NPH Ultralente Lantus other units R - H - other _______________ units Lente NPH Ultralente Lantus other units R - H - other _______________ units Lente NPH Ultralente Lantus other units R - H - other _______________ units Lente NPH Ultralente Lantus other
STUDENT’S SELF-CARE (ability level)
Totally independent management or
student needs verification of number by staff or assist/testing to be done by school nurse 2. Student administers insulin independently or student self-injects with verification of number or student self-injects with nurse supervision or 3. Student self-treats mild hypoglycemia 4. Student monitors own snacks and meals 5. Student tests and interprets own urine ketones 6. Student tests and interprets own blood ketones
HCP _______________________________ (print/type) _________________________signature _____/_____/_____ date
Parent ______________________________ (print/type) _________________________signature _____/_____/_____ date
School Nurse _________________________ (print/type) _________________________signature _____/_____/_____ date
Start date: ____day ____mo. ____yr. Termination date: _____day _____mo. _____yr. or End of school year: _____
Must be renewed at beginning of each school year.

Source: http://www.svsd410.org/cms/lib05/WA01919490/Centricity/Domain/33/Diabetic_Order.pdf

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