children with DIABETES - Healthcare Plan Checklist

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		Healthcare Plan Checklist

Healthcare Plan Checklist

Student Information

Name: Date of Birth:

School/Teacher: Grade:

Parent/Guardian: Address:

Home Phone:
  Mother:
  Father: Work Phone:
  Mother:
  Father:

Other Emergency Contact: Phone:

Physician: Phone:

Medical Diagnosis: Preferred Hospital:

Checklist

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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Last Updated: Wednesday November 26, 2003 09:44:12
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Student Information
Name:	Date of Birth:
School/Teacher:	Grade:
Parent/Guardian:	Address:
Home Phone: Mother: Father:	Work Phone: Mother: Father:
Other Emergency Contact:	Phone:
Physician:	Phone:
Medical Diagnosis:	Preferred Hospital:

Checklist
	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