Nursing Assessment Checklist and Documentation of …



Nursing Assessment Checklist and Documentation of Completion

For Development of an Emergency Care Plan

This is a checklist to track your progress as you develop and implement Emergency Care Plans.

Do not document information on this form that should be in narrative in the nurse notes of the student chart.

SCHOOL YEAR - ______________

For: _______________________________________ DOB: ____________

To Do Dates Completed

| | |

|Review School Information: | |

| |Sent Home with Student on Date____________________________ |

| | |

|Parent Questionnaire/ Forms |Mailed to home address |

|Other __________ |Date______________________________________ |

| | |

| |Date_________________________ |

|Medical/Special Ed Records reviewed | |

| |Date_______________________ |

|Staff Information: | |

|Interview Teachers and Staff as needed |SEE NURSES NOTES Y N |

| Signtures on REQUIRED forms: | |

|* Assessment from parent |( RECEIVED Date:_______________ |

| | |

|* Consent to share information |( RECEIVED Date:______________ |

| | |

|* Medication authorization |( RECEIVED Date:______________ |

| | |

|*Consent for release of medical info |( RECEIVED Date:______________ |

|Contact Health Care Provider: | |

| |Consent for release of information sent |

|Obtain signature for Physician Authorization Form for |If needed |

|medication/treatments, etc. |Authorization form signed |

|Student Assessment / Interview | |

| | |

|Student Issues/ Needs/ Coping |Student assessment Date__________________________ |

|Student actions to prevent emergencies | |

| | |

To Do Dates Completed

| | |

|Staff who need to know…what to do |Staff identified and given information |

|Staff in classroom(s), Staff in school office,on playground, in |AFTER Consent to share information obtained |

|cafeteria, | |

|on field trips, providing transportation | |

| | |

|Necessary materials |Equipment obtained |

|Equipment (nebulizer, scissors, etc.) |Expiration date is________________ |

|Medications (Epi-Pen, etc.) |On RX labeled__________________ |

|Materials (gloves, bandages, etc.) | |

| | |

|**Emergency Care Plan written |Plan written |

| | |

| |Sent home with student Date:____________ |

|Plan Reviewed by parent |Mailed to home Date:____________ |

| | |

| |FAX to ________________________ |

| |Date____________ |

| |Date__________Signed back of ECP |

|Care Plan Sent to PCP to be Reviewed | |

| | |

|Reviewed by Student | |

| | |

|Staff training | |

|Location of plan (copies of plans) |Staff trained, confident |

|Location of equipment/meds | |

|Explicit steps to follow | |

|Practice |Date___________________________ |

|Emergency Care Plan distributed to #1,2,3 trained staff listed on ECP| |

| | |

| |Date____________________________ |

|ECP to Coaches, Transportation staff | |

| |NAMES DATES |

| | |

|ECP TO TEACHERS/STAFF who have a need to know | |

| | |

| | |

|ECP given to School District LPN or health room aide or front office |Date________ |

|staff | |

| | |

|If Emergency Occurs Staff to Complete |911 Emergency checklist |

| | |

|After emergency occurs, debrief with staff, parents students EMS, |Date of debrief |

|health care provider…whatever is appropriate. | |

Completed by School Nurse(s): ________________________________________

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