HEALTH CARE PLAN PROCESS

Transcription

1 HEALTH CARE PLAN PROCESS IDENTIFICATION How are students with health care needs identified in your school? ((link) NOTIFICATION How and when does the school notify the nurse of these students? (link) DEVELOPMENT OF HEALTH CARE PLAN Does every student need a HCP and how do I create one? Approved Standardized Health Care Plan Template (link) RN Assessment of Health Condition Assessment Tools/Questionnaires Creating the Health Care Plan Special Condition s Health Care Plans (link) Health Care Plan Resources (link) Sample Health Care Plans REVIEW AND MODIFY HEALTH CARE PLAN Will I need to make changes to the HCP? SIGNATURES Who needs to sign the finalized Health Care Plan? RN Parent/guardian Health Care Provider s Implementing the Health Care Plan What do I do next, now that I have a written plan? Distribution of Health Care Plan Staff/ Student Training EVALUATION Is this plan working? Delegation of Nursing Tasks

2 DEVELOPING AND USING INDIVIDUALIZED HEALTH CARE PLANS The individualized health care plan (HCP) communicates nursing care needs to regular and special education educators, administrators, teachers, health assistants and parents. The HCP is written by the professional school nurse (RN) for students with a health condition that require the performance of a specific treatment, such as non-routine medication treatment, health treatment, emergency action or invasive health procedure. The Health Care Plan helps to ensure that all necessary information, needs, and plans are considered to maximize the student s participation and performance in school. The students do not need to be classified as special education or having a 504 plan in order to benefit from an individualized health care plan. Not all students in special education or those with a 504 plan necessarily need a HCP. (FLOW CHART) IDENTIFICATION of students needing Health Care Plan How will you find out if a student in your school has a significant health problem that you need to be aware of and will need a HCP? Health Information may be obtained from various sources. The following are examples that your district may already be using or you may want to consider. Emergency forms Your district emergency form should include: name of health care provider with contact information, release for emergency care, statement of current health needs, current medications and health insurance information. This form should be completed by the parent or guardian on an annual basis and with any changes during the school year. Health Inventory It is recommended that the school obtain a more complete health inventory for each student on an annual basis. This information should be collected and kept in a confidential manner. This information will help you decide what health accommodations may be necessary in the school setting. (link to sample) Teacher/Parent/Student/Health Care Provider referrals At the beginning of each year communicate with staff, family and community providers the model of school health services in your school and the referral process to the school nurse. Medication forms Refer to notification form medication section (link) IEP/504/Student Study Team Identify the discipline that collects the health information for the initial special education assessment and triennials. Educate your special education team members on the referral process to the school nurse regarding children with identified health needs. Child Find Identify the discipline that collects the health information for the initial assessment and triennials. Educate your special education team members on the referral process to the school nurse regarding children with identified health needs. Transition or re-entry If a child is hospitalized or absent for an extended period of time, make sure that emergency information and current health needs are updated. NOTIFICATION OF SCHOOL NURSE Key school personnel that may be involved at point of school entry for a student (eg. registration, SPED, child find) should be educated regarding when to contact the school nurse for students with significant health concerns. Entry may be delayed for students requiring specialized

3 procedures or emergency care until a HCP has been developed with the parent/guardian and health care provider. What key health conditions require school nurse notification? (link) DEVELOPMENT OF HEALTH CARE PLAN A HCP helps to ensure that all necessary information, needs and plans are considered to maximize the student s participation and performance in school. The registered school nurse establishes the type, amount and intensity of nursing care required by a particular student in collaboration with the family, school, and healthcare provider. The HCP also covers other aspects of care such as a student s knowledge about their condition, self care abilities and any modifications needed to enhance learning and prevent emergencies RN Assessment of Health Conditions The first step should be an assessment of health needs that may indicate the need to develop a Health Care Plan. The following is a brief checklist to determine if a HCP is needed. Do Health Problems Require: Yes No Special training of school personnel Modification in school environment Added safety measures Measures to relieve pain Self-care assistance Rehabilitation measures Treatments orders for special procedures Special diet Medications or interventions for emergency treatment Assessment Tools and Questionnaires: Questionnaires or assessment forms are available to help in developing the HCP. These forms can be given to the parent to complete or used by the school nurse during the parent interview. The information obtained will be used to complete the HCP. Nurse Consultant Assessment and Checklist for Children with Special Needs (CDE) Planning Checklist for IEP/HCP Development (CDE) Diabetes Intake Form (link) Severe Allergy Intake Form (CDE form) Seizures Questionnaire (link) Asthma Questionnaire (link) NASN samples (Tics/Tourettes, Headache) Creating the Heath Care Plan The following Health Care Plans are the more frequently needed plans and available for use in your school. Remember that this plan will be used by non-medical staff members and should be easy to read and easily understood.

4 Approved Standardized Plans (separate links) Asthma Diabetes Severe Allergy (Children s) Seizures (Epilepsy Foundation) Health Care Plan Template This is a basic form that can be individualized for various health conditions (link to sample form) Health Care Plan Resources The following publications have a wide range of Health Care Plans that may be adapted for use. Computerized Classroom Health Care Plans for School Nurses, 1997 JMJ Publishers 1156 Wilson Ave Salt Lake City, Utah (801) (available on disc) Individualized Healthcare Plans for the School Nurse, 2005 Sunrise River Press Kost Dam Rd North Branch, MN (612) (available on CD) Quality Nursing Interventions in the School Setting, 2004 NASN P.O. Box 1300 Scarborough, ME (877) Disease Specific Resources Asthma: National Jewish Asthma & Allergy Center (web site) Diabetes: Pink Panther Diabetes Book Barbara Davis Center for Diabetes (Available on line and for purchase)

5 Pediatric Education for Diabetes in Schools Helping the Student with Diabetes Succeed Complete online version available at Seizures: Procedure Manuals Children and Youth Assisted by Medical Technology in Educational Settings, Stephanie Porter, et al. Paul H Brookes Publishing Company P.O. Box Baltimore, MD Quality Nursing Interventions in the School Setting NASN P.O. Box 1300 Scarborough, ME (877) REVIEW AND MODIFY HEALTH CARE PLAN After reviewing the initial Health Care Plan with parent/guardian, school personnel, student, or health care provider, you may find that changes are necessary. The draft Health Care Plan may be available in the interim to key school personnel until the plan is finalized. SIGNATURES The school nurse should sign and date all Health Care Plans. Parent/guardian signature should be obtained for all plans that include medications, treatments or procedures that need to be performed during the school day. The signature of the Health Care Provider with prescriptive authority is required on all plans with medications, treatment or special procedure orders. Note: if Health Care Provider s signature is documented elsewhere (eg medication form, written authorization), additional signature of Health Care Provider on the health care plan is not needed. signatures that may need to be included are students and/or administrators. Districts should establish procedures that clarify what signatures are required. IMPLEMENTING THE HEALTH CARE PLAN Distribution of Health Care Plan Health Care Plans contain confidential information and by law may only be shared only with individuals in the school setting who have a specific and legitimate educational interest in the

6 information. Health information in the educational setting is regulated under FERPA (Federal Educational Records Privacy Act). Individuals who may need access to the plan include the classroom teacher, team leader, office staff, bus drivers, specials teachers, support services, special education staff, paraprofessionals, recess aides, cafeteria staff, and administrative staff. Advise the classroom teacher to keep a copy of the plan in a confidential folder for substitute teachers. copies should be kept in the student s health folder and in a central location (eg. health room or front office) easily accessed by staff for emergencies. ing of plans is discouraged due to security issues. A list of staff who have received the Health Care Plans should be maintained. Staff/Student Training The school nurse in consultation with the student s parents and health care providers, should use information from a thorough health assessment to determine the following: Level of care needed Equipment needed Personnel qualified to provide for the student s health care needs Modifications or accommodations Topics of training should include: Confidentiality Overview of student s health condition Review of health concerns/emergencies and action(s) to be taken as outlined in the health care plan Student specific health care procedures may also include delegation to designated personnel who demonstrate competency to the RN. (see delegation section) Roles and responsibilities of school personnel including transportation and emergency planning Training should be provided and updated on an annual basis and when the student s health condition or equipment changes. Training should be documented. Delegation of Nursing Tasks Delegation is the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome. (ANA 1992) Nursing tasks and procedures may be delegated by the supervising school registered nurse based upon nursing judgment, however the professional nursing judgment of assessment, evaluation, and care planning may not be delegated to unlicensed school personnel. The delegating RN determines whether a nursing task or procedure can be properly and safely performed by unlicensed school personnel. A nursing task or procedure can be delegated by the school registered nurse provided the unlicensed school personnel has demonstrated competency to perform the task through the training process. A schedule for periodic evaluation of continuing competency of unlicensed school personnel should be established by the RN. The delegating nurse should determine the frequency of evaluation. Refer to the CDE: The School Nurse and Delegation.

7 Colorado Nurse Practice Act Delegation Clause (Chapter 13 link) Criteria for Determination of Delegation to Unlicensed Personnel in the School Setting (link) jeffco Procedures Requiring Delegation and/or Training to Unlicensed School Personnel (link) needs to be reviewed by Judy / BON*** Individualized Procedures and Checklist Children and Youth Assisted by Medical Technology in the Educational Setting (link) is a good reference book that contains various procedures and checklists for skill demonstration to help you document delegation and review of competency. EVALUATION School nurse should review and update the Health Care Plan annually and when changes occur in the health status of the student. The Health Care Plan is not a onetime event but rather is a dynamic document that should be evaluated periodically. Evaluation process includes reviewing the desired student goals and outcomes and determining the appropriateness and effectiveness of the Health Care Plan in the school environment. Care coordination should include periodic assessment and documentation of student response to Health Care Plan and/or treatments.

8 STUDENT HEALTH INFORMATION School Year : STUDENT NAME: Birthdate: Grade: School: HEALTH CONCERNS YES NO MEDICATION (Name, dosage) ASTHMA/ RESPIRATORY SEVERE ALLERGIES DIABETES HEAD INJURY SEIZURES/ NEUROLOGICAL/ MIGRAINES HEART/BLOOD MUSCLES/BONES/ JOINTS/SKIN BLADDER/KIDNEY STOMACH/ INTESTINES/BOWELS IMMUNE PROBLEMS OTHER HEALTH CONCERNS HEARING CONCERNS VISION CONCERNS GROWTH & NUTRITIONAL CONCERNS DEVELOPMENTAL CONCERNS EMOTIONAL/ BEHAVIORIAL NECESSARY MONITORING IN SCHOOL FOOD LATEX INSECTS NUTS Equipment: Hearing aides? Preferential seating? Glasses or contacts? Reading only? COMMENTS OR DESCRIBE type of reaction date of last reaction: Type & date of last episode Routine or daily medications, treatments or therapies (not listed above): Activity restrictions in school? Special medical equipment required in school? (eg. oxygen, wheelchair) Have there been any significant changes in your child s health over the last year? Explain: ILLNESSES, HOSPITALIZATIONS, ACCIDENTS/ INJURIES and dates: (use other side if necessary) Health Care Provider(s) & Phone #: PARENT/GUARDIAN SIGNATURE HOME/WORK PHONE # DATE completed: Name of school nurse: your school nurse can be reached at: Please contact the school nurse directly if you would like to discuss any of the above information that you feel is confidential.

9 CHILDREN WITH SPECIAL HEALTH CARE NEEDS Immediately notify school nurse (RN) regarding the following significant student health concerns Medications Injectable (e.g., EpiPen, insulin, glucagon) Nebulizer treatments Rectal Homeopathic preparations Potential life threatening conditions such as: Severe allergies (e.g., insect sting, food, nuts, latex ) Diabetes Neurological disorders: Seizures Significant head injuries or concussion (look for time frame) Significant heart conditions Significant respiratory conditions Asthma; where child is on regular medications Child who is on oxygen (at home, child care or school) Special health conditions Bleeding disorders Cancer Weakened immune system HIV/Aids; Hepatitis B or C Organ transplant Special equipment such as: Central Line (IV) Glucometer (testing blood glucose) Insulin pump Gastrostomy tube Tracheostomy tube Catheters (urinary) Colostomy Vagal Nerve Stimulator (VNS) Wheelchairs or crutches conditions that may require nursing consultation: Nutritional concerns Health resource referral Infectious disease Chronic illness Recent injuries Recent hospitalization Hearing/Vision concerns Hypoglycemia Migraines Special bathroom needs The Children's Hospital School Health Program, Denver, CO (2000, revised 2005)

10 CONFIDENTIAL NURSE CONSULTANT ASSESSMENT AND CHECKLIST FOR CHILDREN WITH SPECIAL NEEDS NAME: BIRTHDATE: Parent/Guardian s names: Phone during daytime: Address: Physical Assessment: = Normal Ears, Nose Eyes Indicate if performed by RN or source of records reviewed Abdomen Genitalia Mouth, throat Extremities/joints Lungs Spine Cardiovascular Blood Pressure Dental Screening Skin, lymph nodes Allergies Date Height Weight BMI Immunizations Hct. Hgb. Date Date Hearing/Results Vision/Results Nutrition/Diet Current Medications Technology CURRENT HEALTH ISSUES: PERTINENT HEALTH HISTORY: FAMILY HEALTH SERVICES IMPORTANT PERSONNEL Goals/priorities Collaboration/Liaison Communications Health assessment, including student strengths Individualized health care plan Emergency plans Health status monitoring Specialized health procedure Health teaching/counseling Medication Personnel training Personnel supervision Staff consultation- Family support/liaison Health Care Provider consultation/orders Parent authorization(s) Release of info to/from health care provider School contacts Direct caregivers Substitute caregivers/back-up staff Transportation personnel General staff training date: Peer awareness training date: Specific student training date Specific student training date: Specific student training date: The Children s Hospital School Health Program, Denver, CO (2004)

11 CONFIDENTIAL NURSE CONSULTANT ASSESSMENT AND CHECKLIST FOR CHILDREN WITH SPECIAL NEEDS NAME: BIRTHDATE: TRANSPORTATION TUTORING/ HOME/ HOSPITAL OTHER PROGRAM ADAPTATIONS ACCESS FIRE SAFETY SCHEDULE THERAPIES RELATED SERVICES Vehicle/Access Special Assistance/Aide Equipment Positioning Emergency Plan/Evacuation/Safety Communications Supplemental in-school tutor--regular, intermittent Plan for continuous programming--school/home/hospital Extra set of books at home Regular home/hospital program Curriculum/instruction Special Equipment Activities of daily living Scheduling of health interventions Positioning/Mobility Special diet School entrance Hallways Stairs/elevator Personal facilities Bathroom Health Room Cafeteria Library Evacuation Plan/Practice Locker Physical Recreation Areas (gym, playground,etc) Special Classroom Back-up plan Length of day Number of days Rest periods Flexible schedule Testing schedule Occupational therapy Physical therapy Speech/language pathology Labs Social Work Counseling/Mental Health EXTRA CURRICULAR ACTIVITIES FIELD TRIPs Special learning opportunities Extended day program/child care Clubs/Sports/Social Events Transportation/Access Medication Plan Emergency Plan Personnel Transportation Designated Staff Trained: The Children s Hospital School Health Program, Denver, CO (2004)

12 PLANNING CHECKLIST FOR IHCP AND IEP DEVELOPMENT For Students with Special Health Care Needs FAMILY Goals/priorities Liaison Collaboration Communications HEALTH SERVICES Health assessment, including student strengths Individualized health care plan Emergency plans Health status monitoring Specialized health procedure Health teaching/counseling Medication Personnel training Personnel supervision Staff consultation Family support/liaison Physician consultation/orders Parent authorization(s) Release of info to/from health care provider TRANSPORTATION Vehicle Access Safety Equipment Positioning Emergency Plan Communications Special Assistance Evacuation Aide TUTORING/HOME/HOSPITAL Supplemental in-school tutor--regular, intermittent Plan for continuous programming-- school/home/hospital Extra set of books at home Regular home/hospital program OTHER PROGRAM ADAPTATIONS Curriculum/instruction Special Equipment Activities of daily living Scheduling of health interventions Positioning Mobility Special diet ACCESS School entrance Hallways Stairs/elevator Classroom/specials Bathroom Health Room Cafeteria Library Locker Gym Playground FIRE SAFETY Evacuation Plan Evacuation practice Back-up plan other SCHEDULING Length of day Number of days Rest periods Flexible schedule Testing schedule THERAPIES Occupational therapy Physical therapy Speech/language pathology OTHER RELATED SERVICES Social Work Counseling Psychology EXTRACURRICULAR ACTIVITIES Special learning opportunities Extended day program Clubs Sports Social Events Transportation Access FIELD TRIPS Medication Plan Emergency Plan Personnel Transportation Source: Adapted with permission from (C. Perreault), Children with Special Health Care Needs in School and Child Care, in Pediatric Home Care, 2nd edition, Townsend and Votroubek, eds., 1997, Aspen Publications The original version of this checklist was published by the Federation for Children with Special Needs as Checklist of items for consideration in developing IEP s for students with physical disabilities or special health needs. This adaptation appeared in Serving Students with Special Health Care Needs, Connecticut State Department of Education, It is used here with permission of both source

13 SCHOOL INTAKE INTERVIEW - DIABETES Student Date of birth School Grade Homeroom Teacher Parent(s)/Guardian(s) Phone (H) (W) () Emergency contact (other than parent /guardian) Phone Physician name Office Phone Fax Diabetes Nurse Educator s name Office Phone Medical release of information signed? Yes No Mode of transportation to and from school? Bus driver notified of diabetes? Yes No Does child participate in after school activities? Yes No Before or after care? Explain Adult leader notified of diabetes? Yes No Field trip recommendations: Blood Sugar Monitoring: Test will be performed in (location). Needs assistance with testing? Yes No Explain Required test times Call parent if blood sugar below or above Staff to record values and report to parents daily weekly Comments: Meds: Insulin: Can child give own injections? Yes No Explain Order for insulin on file? Yes No Time(s) insulin is to be administered at school: Type/Dosages: Form of administration: (Injection, Pen, Pump) Oral medications: Type Times Dose Comments: Diet: Assigned student lunch time(s)? Is child following a prescribed meal plan? Yes No Assistance required? Yes No Explain Snack time(s)? Assistance required? Yes No Explain Snack will be eaten in (location) Snacks will be stored in (location) Recommended snacks Parent wishes to be notified in advance of class parties? Yes No Child may partake in class treats? Yes No Explain Comments: Physical Education: Scheduled at: Is snack necessary before physical education? Yes No Does child participate in after school sports? Yes No P.E. Teacher/Coach aware of child s diabetes? Yes No Comments:

14 QUESTIONNAIRE FOR PARENT OF A STUDENT WITH ALLERGIES It has come to our attention that your student has allergies. The school nurse needs more information on your student's allergies to help us take care of your student at school. Please complete this form and return to school. If you have any questions about how to complete this form, please contact your student s school nurse. Nurse s Name: Phone: Student Name: Parent/Guardian Name & Phone#: Parent/Guardian Name & Phone#: Emergency Contact Name & Phone#: Primary Care Provider & Phone#: Allergy Care Provider & Phone#: Preferred Hospital: Birth date 1. What is your student allergic to? How severe is your student s allergic reaction? Foods (specify type ) Mild; Moderate; Severe; Foods (specify type ) Mild; Moderate; Severe; Foods (specify type ) Mild; Moderate; Severe; Insect sting (specify type ) Mild; Moderate; Severe; Animals, pets (specify type ) Mild; Moderate; Severe; Latex Mild; Moderate; Severe; Pollens (grass, flowers, trees) Mild; Moderate; Severe; Dust, dust mites Mild; Moderate; Severe; Mold Mild; Moderate; Severe; Medications Mild; Moderate; Severe; (specify ) Mild; Moderate; Severe; 2. If your student has a food allergy can he/she be in the presence of others eating the food? YES NO 3. When was your student first diagnosed? 4. Was allergy testing done? YES NO; If YES, what kind: RAST(blood) Skin : Test results: 5. When was your student s last significant allergic reaction? What allergy caused the reaction? 6. What symptoms occurred? Hives; Rash; Swelling/itching of lips, tongue, mouth, face; Throat tightness; Cough; Wheezing; Shortness of breath; Nausea; Cramps; Vomiting; Diarrhea; : 7. Please list the medications your student takes (every day and as needed) or include a copy of your student's Allergy Action Plan. MEDICATIONS TAKEN AT HOME Medication Name? How Much? When is it taken? MEDICATIONS TO BE TAKEN AT SCHOOL* Medication Name? How Much? When is it taken? 8. Does your child s allergy care provider recommend that your child carry and self administer his/her own medication? _Yes _No _Don't know 9. Can this information be shared with classroom teacher(s) and other appropriate school personnel? YES NO *I understand that I need a permission form for each medication my child needs to take at school signed by myself and my child s health care provider (a signed Allergy Action Plan will suffice). Parent/Guardian s Signature: The Children s Hospital School Health Program, Denver, CO 2005 Date:

15 QUESTIONNAIRE FOR A PARENT OF A STUDENT WITH ASTHMA OR BREATHING PROBLEMS It has come to our attention that your child has asthma or breathing problems. The school nurse needs more information on your child's asthma to help us take care of your child at school. Please complete this form and return to school. If you have any questions about how to complete this form, please contact your child s school nurse. Nurse s Name: Phone: Student Name: Parent/Guardian Name & Phone#: Parent/Guardian Name & Phone#: Emergency Contact Name & Phone#: Primary Care Provider & Phone#: Asthma Care Provider & Phone#: Preferred Hospital: Birth date 1. On a scale of 1-5, rate how severe your child s asthma is, where 1 = not severe and 5 = severe Please circle 2. How many times has your child been treated in the emergency department or hospitalized for asthma in the past 12 months? _0 times _1 time _2 times _3 times _4 times _5 or more times 3. What triggers your child's asthma or makes it worse? Pollens (grass, flowers, trees) Cigarette smoke Exercise, sports Mold Having a cold, sinusitis Animals, pets Chalk, chalk dust Changes in weather Cockroaches Foods, medications Paints, cleaning agents, new furnishings Stress, emotional upsets Dust, dust mites Strong odors, perfume, dry-erase markers 4. Does your child use a peak flow meter (something he/she blows into to check his/her airway)? _Yes _No _Don't know 5. Do you know what your child's personal best peak flow number is? _Yes What is it? No 6. Please list the medications your child takes for asthma or allergies (every day and as needed) or include a copy of your child's Asthma Action Plan. MEDICATIONS TAKEN AT HOME Medication Name? How Much? When is it taken? MEDICATIONS TO BE TAKEN AT SCHOOL* Medication Name? How Much? When is it taken? 7. How well does your child take his/her asthma medications? _Takes medicine by self as prescribed _Often forgets to take medicine _Needs help to take medicine _Not using medicine now 8. Does your child s asthma care provider recommend that your child carry and self administer his/her own medication? _Yes _No _Don't know 9. Can this information be shared with classroom teacher(s) and other appropriate school personnel? YES NO *I understand that I need a permission form for each medication my child needs to take at school signed by myself and my child s health care provider (a signed Asthma Action Plan will suffice). Parent/Guardian s Signature: Date:

16 ADDITIONAL QUESTIONS FOR PARENT OF A STUDENT WITH ASTHMA OR BREATHING PROBLEMS 10. For each season of the year, to what extent does your child usually have asthma symptoms? (Mark an X for each season below.) A lot A little None Fall Winter Spring Summer 11. Does anybody in the household smoke? _ Yes _ No 12. In the past month, during the day, how often has your child had coughing, wheezing, or breathing difficulties? 13. _ 2 times a week or less _ More than 2 times a week _ Every day (at least once every day) _ Constantly (most or all of the time, every day) 14. In the past month, during the night, how often does your child wake up or have coughing, wheezing, or breathing difficulties? 2 times a month or less _More than 2 times a month _More than 2 times a week _Every night 15. How many times do you refill your child s prescription for quick-relief canisters each year? 16. Does your child have a written Asthma Action Plan? _Yes _No _Don't know 17. Does your child usually use a spacer or holding chamber with his/her metered dose inhaler (a clear tube that attaches to the inhaler and better helps the inhaled medicine get into the lungs)? _Yes _ No _ Don't know _ He/she uses a dry powdered inhaler, so spacer not needed 18. Do you use anything else for your child s asthma (tea, herbs, home remedies, etc.) beside the medications listed? 19. During the past year, how much has your child's asthma stopped him/her from taking part in sports, recess, physical education, or other school activities? Never _Once in a while _Fairly often _Frequently Adapted from: NASN School Nurse Asthma Management Program (SNAMP) Resource Manual CD-ROM Worksheet for Gathering Information from Parent/Guardian About Student with Asthma or Suspected Asthma and Minneapolis Public Schools Healthy Learners Asthma Initiative (disbanded March 2005)

17 School District Logo Confidential Individualized Health Care Plan/ School Year Pg of 1 School Nurse Name & Phone Number (School Fax) Student Name DOB School/Grade Student # Parent/Guardian: Name & Phone # Parent/Guardian: Name & Phone # Authorized Health Care Provider Primary & phone # Authorized Health Care Provider Specialist & phone # Preferred Hospital: HEALTH CONCERN: HISTORY: (brief history and background if pertinent) CURRENT MEDICATIONS: ALLERGIES: if relevant ACTIVITY RESTRICTIONS: if relevant GOAL: SYMPTOMS: INTERVENTIONS: (what to do) SAFETY: evacuation plan As parent/guardian of the above named student, I give my permission for use of this plan in my child s school and for the school nurse to contact the above named health care provider regarding this health care plan. parent/guardian date student (optional) date health care provider date school nurse date principal date

18 Criteria for Determination of Delegation to UAP in the School Setting Student: School: Grade: Task for review: Elements for Review Circle the appropriate answer Comments Within the delegating nurse's area of responsibility? Yes or No Within the knowledge, skills and ability of the nurse delegating the task? Yes or No Nursing Assessment: Level of Client Chronic/stable/predictable Stability Minimal potential for change Moderate potential for change Unstable or strong potential for change Level of UAP's UAP knowledgable and experienced in task to be delegated Ability to Perform UAP has minimal knowledge/experience but willing and able to learn task Task UAP not available,willing, or able to perform task to be delegated Number of UAP available to perform delegated task Number of UAP necessary to perform delegated task safely Level of Decision- Does not require decision making Making Required Minimal level of decision making of UAP Moderate to High level of decision making Has a predicatable outcome Complexity of Unit dose Delegated Task Minimal steps Multi-steps required Potential Risk of None Delegated Task Low Medium High Risk of harm for student if task not delegated Degree of None Invasiveness Low with Task Medium High Frequency of task Performed daily to be performed Performed at least weekly by UAP Performed at least monthly Performed less than monthly Available but may never be performed Approximate Average 3 minutes or less EMS Response Average 3-10 minutes Time Average greater than 10 minutes Ability for Client Will never be able to perform task to Learn and Will require extensive assisstance Perform Task Will require limited assisstance Will be able to perform task independently Determination to Delegate: Yes or No Nurse Signature: Date: Adapted from National Council of State Boards of Nursing (Regulation - Delegation and UAP issues) by Jefferson County School District - Department of Health Services Process Review 1/04

19 Has the RN completed an assessment of student's nursing care needs? YES DELEGATION DECISION TREE* NO Do assessment, then consider of delegation. Is the task within the RN's scope of practice? YES Is the task reasonable and prudent and consistent with the student's health and safety? YES Has the RN validated the delegatee is trained and competent to do the task? YES Are the consequences of improper task performance life threatening for the student? NO NO NO NO YES Do not delegate. Do not delegate. Provide and document training, then consider delegation. OR Do not delegate. Do not delegate. Does the task require nursing judgment or repeated nursing assessments? NO YES Do not delegate. Does the task involve complex observations or critical decisions by the delegatee? YES Do not delegate. NO Is the task of a routine, repetitive nature requiring exact unchanging directions? YES Are the results of the task reasonably predictable? YES NO NO Do not delegate. Do not delegate. Is the RN able to provide appropriate supervision? NO Do not delegate. YES Does the RN's agency have a policy which allows delegation of this task to the delegatee? YES The task may be delegated to a specific delegatee for this student ONLY NO Do not delegate. The Children's Hospital School Health Program, Denver, CO 2005 *Based on works by National Council for State Boards of Nursing

20 Procedures Requiring Delegation and/or Training to Unlicensed School Personnel Procedure Medical Order Needed RN Train/ Delegation Needed Minimum Review of Competency RN to Instruct Staff RN Task Activities of Daily Living (ADL) Toileting/Diapering No Yes No Yes Toilet Training No Yes No Yes Dental/Oral Hygiene No Yes No Yes Lifting/Positioning No Yes No Yes-OT/PT to assist Feeding Oral No Yes No Yes NG Tube Yes Yes Yes Yearly - (bolus/slow drip) G-tube (bolus Yes Yes Yes Yearly - slow drip) J-tube (bolus/slow Yes Yes Yes Yearly - drip) IV TPN feeding Yes Yes No - NG Insertion Yes Yes No - NG Removal Yes Yes No-ER only - GT Reinsertion Yes Yes No - Catheters Clean Intermittent Yes Yes Yes Once a - Cath Sterile Cath Yes Yes Yes Once a - Indwelling Cath Yes Yes Yes Once a - Care Crede Cath Care Yes Yes Yes Once a - Medical Support VP Shunt Yes Yes Yes Yearly - monitoring VP Shunt pumping Yes Yes No - in ER Mechanical Ventilator Monitor Vent Yes Yes Yes Once a - Adjust vent Yes No No - Vent equipment Yes Yesin No - failure ER Pulse Oximeter Monitoring Yes Yes Yes-with parameters Once a -

21 Procedures Requiring Delegation and/or Training to Unlicensed School Personnel Procedure Intermittent Oxygen Continuous/monitor oxygen Medical Order Needed RN Task RN Train/ Delegation Needed Yes Yes Yes-with parameters Yes Yes Yes-with parameters Minimum Review of Competency Once a Once a IV s Hickman/Broviac Yes Yes No - Central Line Yes Yes No - Heparin Lock Yes Yes No - IV dressing change Yes Yes No - Peritoneal Dialysis Yes Yes No - Apnea Monitor Yes Yes Yes Once a Ostomies Ostomy Care Yes Yes Yes-ER only Ostomy Irrigation Yes Yes No - Dressing Changes Sterile Yes Yes No - RN to Instruct Staff Decubitus Ulcer Yes Yes No - Care Respiratory Postural Drainage Yes Yes Yes Yearly RT to aid Chest Percussion Yes Yes Yes Yearly OT/.PT/RT may assist Suctioning Oral/Nasal Yes Yes Yes Once a Trach Yes Yes Yes-no deep 3 months - suctioning Trach tube Yes Yes No - replacement Trach Care Yes Yes No - Diabetic Care Blood Glucose Yes Yes Yes Once a - Testing Ketone Testing Yes Yes Yes Once a - Insulin Injections Yes Yes Yes-with 3 months - parameters Glucagon injection Yes Yes Yes 3 months - Insulin Pump Yes Yes Yes 3 months

22 Procedures Requiring Delegation and/or Training to Unlicensed School Personnel Procedure Medical Order Needed RN Train/ Delegation Needed Minimum Review of Competency RN Task *Routine Medications Oral Yes Yes Yes Yearly - Epipen Yes Yes Yes Yearly - Inhalers Yes Yes Yes Yearly - Nebulizer Yes Yes Yes Yearly - treatments Ear/Eye Drops Yes Yes Yes Yearly - Topical Yes Yes Yes Yearly - **Non- Routine Medications Injection-SQ Yes Yes Yes 3 months - Injection-IM Yes Yes No - Rectal Yes Yes Yes 3 months - NG Meds Yes Yes Yes Yearly - IV Meds Yes Yes No - Spirometry Yes Yes Yes Yearly - Development of: HCP - Yes NA - Emergency Plans - Yes NA - IEP Heath Objectives - Yes NA - RN to Instruct Staff *Routine medication administration is addressed in the Medication Administration Instructional Program. (link to medication) This manual and curriculum is designed to give unlicensed personnel basic information in the administration of medication. Training alone does not constitute delegation. After completion of training unlicensed personnel must demonstrate competency in the performance of the task of medication administration. ** Non-routine medications require 1:1 delegation, if it is appropriate to delegate such medications for a child with a stable condition. This will be based on individual situations utilizing the current HCP for the child. Note: For adequate coverage, it is recommended that each of these procedures be delegated to at least 3 staff members. Adapted from The Medically Fragile Child in the School Setting, American Federation of Teachers, Second edition.