Policy Details

5141.25 FORM 6 Individualized Healthcare Plan (Elementary)

INDIVIDUALIZED HEALTHCARE PLAN (Elementary)
Student Name: ______________________________ Birth Date: ______________ Grade: __________ Teacher: _____________________________
Plan effective from 2006 to 2007
ASSESSMENT DATE/NURSE FUNCTIONAL HEALTH CONCERN STUDENT OBJECTIVE(S) INTERVENTIONS EVALUATION
Risk of anaphylactic reaction (life-threatening allergic response) related to the ingestion or inhalation of peanuts and/or tree nuts (protein component) Student will cooperate with staff 100% of the time by following school, classroom and IHCP rules in order to remain free of allergic reactions while in school. Parents will: [Enter documentation method or date(s) accomplished for all applicable inteventions]
² inform school nurse and teacher of food allergy
² provide a physician's order and medication for medical intervention
² inform school nurse of any changes in health status as relates to food allergy and treatment
² educate student in the self-management of his/her food allergies appropriate for his/her age level
Risk of severe allergic reaction to the ingestion or inhalation of [add other allergens here if applicable, or delete] If student suspects that he/she has ingested (fill in food allergens), student will immediately notify staff who will implement the IECP according to the allergen-specific plan.
² provide emergency contact information
² meet with school nurse to develop a prevention plan
² provide safe snacks/treats for student to keep in school and, if desired, a list of appropriate foods for student to have at snack
Student has an Nurse will:
Individualized Emergency Student will cooperate with staff members 100% of the time if they need to implement the IECP. ² meet with parents and teacher to develop a prevention plan
Care Plan (IECP)
² post "peanut/nut free" sign outside of classroom
² work with teacher to eliminate the use of peanuts/tree nuts in classroom snacks, curriculum, educational tools, classroom parties, foreign language projects, and arts and crafts projects
² educate school staff who interact with student regarding food allergy, allergic reaction symptoms, recognizing signs and symptoms of anaphylaxis, and prevention and treatment plans
² train school staff in EpiPen administration, as appropriate
² develop and disseminate emergency care plan for student
² review cleaning/care of nut/peanut free table in cafeteria with maintenance and cafeteria staff
INDIVIDUALIZED HEALTHCARE PLAN (Elementary)
Student Name: ______________________________ Birth Date: ______________ Grade: __________ Teacher: _____________________________
Plan effective from 2006 to 2007
ASSESSMENT DATE/NURSE FUNCTIONAL HEALTH CONCERN STUDENT OBJECTIVE(S) INTERVENTIONS EVALUATION
Teacher/classroom staff will:
² eliminate the use of nuts/peanuts in classroom snacks, educational tools, and arts and crafts projects.
² be trained in the administratin of EpiPen, as appropriate
² consult in advance of field trips with the school nurse and parents
² [for food allergens other than peanut/nut] notify parents in advance regarding curriculum/projects that may contain [add these food allergens]
² follow the emergency care plan if student has a reaction
Student will:
² not eat any foods except those that come from home or have been approved by the parent
² inform teacher/staff if he/she is not feeling well, for any reason, but expecially if he/she thinks he/she may be having an allergic reaction
School Nurse: _________________________________________ Date: _______________
Review by: Parent: _________________________ Date: _______________ Student: _________________________ Date: _______________


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