Back to Diabetes Management at School Healthcare Plan Checklist

Healthcare Plan Checklist

Student Information
Name: Date of Birth:
School/Teacher: Grade:
Parent/Guardian: Address:
Home Phone:
Work Phone:
Other Emergency Contact: Phone:
Physician: Phone:
Medical Diagnosis: Preferred Hospital:

  Date Requested Date Received
1. Referral received from:    
2. Parent contact    
3. Authorization for release of information signed by parent/guardian    
4. Medical/nursing/educational records    
5. Nursing assesssment: Home visit, school site observation    
6. Individualized Health Care Plan complete    
7. Emergency Action Plan developed    
8. Request for written orders to physician    
9. Parent Request for Special Care on file    
10. Review of procedure with parent/guardian    
11. Staffing/placement meeting    
12. Staff/In-service training    
13. Transportation plan completed    
14. Equipment and supplies checklist    

School Nurse Signature   Date

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