Skills Assessment Form - Florida · Skills Assessment Form ... Risk for Ineffective Airway Clearance. Anxiety related to ... • Encourage fluids to decrease thickness of lung secretions

Exhibit 1

Skills Assessment Form

Health Support Technician:_________________________________ Date:____________________

Nurse Supervisor:_________________________________ School:___________________________

Procedure Performs activity in accordance with policy & procedure guidelines

Does not perform activity in accordance with policy and procedure guidelines

Requires further instruction & supervision

ANAPHYLAXIS Administration of Epinephrine Auto Injector Caregiver Epi-Pen Kit List

ASTHMA Metered Dose Inhaler Administration Nebulizer Administration

DIABETES Blood Glucose Monitoring Ketone Testing Carbohydrate Counting Insulin Injection via Pen or Syringe I n s u l i n Pump Procedures

SEIZURES Diastat Administration Caregivers Diastat Kit List Seizure Log TRAINER

CHILD ABUSE AND NEGLECT Recognizing Child Abuse Reporting Child Abuse

Exhibit Page 1 of 66

Student Assessment Check List School Year 20___- 20___

Allergies: __________ _____

Student’s Name: DOB: Age: Parent/Guardian: ___ Contact #: Other/Relationship: ___ Contact #: ______

Guidelines for Student Planning • IHP will be developed for students with a significant chronic disease (i.e.: severe asthma, diabetes, seizure

disorder, anaphylaxis, and psychotropic meds).

• ECP will be developed for students with a potential risk of emergency.

Indications: Students with any of (but not limited to)

the following condition(s) may need an IHP. Please check all that apply.

Assessment Checklist. Does health problem require any of the following?

Please check all that apply.

Allergies Diabetes Asthma Seizure Disorder ADHD Autism Eating Disorder Blood Disorder Cardiac Disorder Respiratory Disorder Psycho/Social Issues Hearing Impairment Visual Impairment Other__________________________________

Special orders for care from a healthcare provider Medication and authorization Special training of school personnel Special diet Change in school environment Added safety measures Measures to relieve pain Self-care assistance Other______________________________________Comments/History:_____________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________

Student needs IHP only Student needs IHP and ECP No plan required at this time

RN signature: Date:

Exhibit 2

DOH-Broward N-88 09/16 Exhibit Page 2 of 66

Individual Health Care Plan School Year 20___- 20___

Exhibit 3

Allergies: Previous Episode of Anaphylaxis:

Describe Incident:

Student’s Name: DOB: Age: Parent/Guardian: Contact #: Secondary Emergency Contact/Relationship: Contact #: Name of Healthcare Provider: Contact #:

In Case of EMERGENCY Call 911 ASTHMA, check all that apply

Assessment Data Nursing Diagnosis Goals Nursing Interventions Expected Outcome

Medication/TreatmentAuthorization orAsthma Action Planfrom HealthcareProvider.Yes___ No___

Medication to beadministered by:Staff___Student___

Risk for IneffectiveAirway Clearance.

Anxiety related todisease process.

Knowledge deficitrelated to diseaseprocess.

Avoid asthma and orallergy triggers.

Provide and evaluatemedication as orderedon MedicationAuthorization.

Student will learn toidentify early warningsigns of asthmaepisode.

Student will learn toutilize calmingtechniques.

School staff will identifyearly warning signs ofrespiratory distress.

School staff/Schoolnurse will implementthe Emergency CarePlan.

Teachers and staffwill be trained onrecognizing signs andsymptoms of Asthmaand how/when torespond.

Provide emotionalsupport.

Coach student to userelaxation techniques.

Student’s safety ismaintained.

Asthma medication isdelivered efficiently andeffectively.

Name and date of staff members instructed: Classroom Teacher(s) Special Area Teacher(s) Administration Support Staff

Reviewed with parent/guardian: Name: in person by phone.Must make no less than two attempts to contact parents/guardian: __________ __________ ECP Completed.

Date 1 Date 2

RN signature: Date:

This plan is in effect for the current school year and summer school as needed.

DOH-Broward N-92 09/16 Exhibit Page 3 of 66

School Year 20___- 20___ Allergies: Student’s Name: DOB: Age: Parent/Guardian: Contact #: Secondary Emergency Contact/Relationship: Contact #: Healthcare Provider: Contact #:

Asthma

Student Asthma Symptom History Asthma Triggers (please check all that apply): Exercise Stress Dust Pollen Smoke Mold Air pollution Animal hair/fur Change in Temp Seasonal Allergies __________________________________ Foods____________________________________________ Other ____________________________________________ ____________________________________________________ ____________________________________________________ _____________________________________________________

Asthma Symptoms (please check medical history) : Changes in breathing: Coughing, Wheezing, Breathing through mouth, Shortness of breath Verbal reports of: Chest tightness, Doesn’t feel well, Speaks quietly, Cannot catch breath, Dry mouth Appears: Anxious, Pale, Sweating, Nauseous, Fatigued, Shoulders hunched over, Difficulty walking and/or talking

Green Zone, Mild Yellow Zone, Moderate Red Zone, Severe Doing well, no coughing or

wheezing. Can work and play. Sleeps well at night.

Some coughing or wheezing shortness of breath or chest tightness.

Difficulty walking and/or talking.

Quick relief medication: ______ _________________________

Difficulty breathing. Cannot work or play. Getting worse instead of better. Medication is not helping after 10-15 min.

Asthma Emergency Action Steps The severity of symptoms can change quickly.

It is important that treatment is given immediately in the order that places the student’s safety first. • Stop activity immediately. Stay with student at all times. • Stay calm. Help student assume a comfortable position (Sitting up is usually more comfortable). • Notify School Nurse or Trained Personnel (see below). Call parent or guardian (listed above). • Administer medication as ordered:_____________________________________________________________

o Medication stored: Health room Self Carries Other: ______________________ • Observe for relief of symptoms. If no relief noted in 10-15 minutes, follow steps below for an asthma emergency. • Encourage purse-lipped breathing. • Encourage fluids to decrease thickness of lung secretions. • Time, observe, and record what happens (note symptoms, over all appearance, skin color, respiratory rate and pattern of

breathing). If symptoms don’t improve: • Call 911- Inform EMS that you have an Asthma Emergency. They will ask the student’s name, age, physical symptoms,

and what medications he/she takes daily and what has been given for this event (Medication Authorization form). • Other instructions: ____________________________________________________________

Reviewed with parent/guardian: Name: _____________________________________________in person by phone.

ECP distributed to staff on a need to know basis. Personnel training date: ____________________________________

Trained Personnel: ________________________________ Trained Personnel: ________________________________

RN signature: _________________________________________________________Date: _______________________

Exhibit 3A

This plan is in effect for the current school year and summer school as needed. DOH-Broward N/91 09/16



Exhibit 4

Allergies:

Student’s Name: DOB: Age: Parent/Guardian: Contact #: Secondary Emergency Contact/Relationship: Contact #: Name of Healthcare Provider: Contact #:

In Case of EMERGENCY Call 911

DIABETES, please check all that apply Assessment Data Nursing Diagnosis Goals Nursing Interventions Expected Outcome

DMMP or

Medication/Treatment Authorization on file.

Exp. Date: ________ Insulin to be given

during school? Yes____ No_____

Insulin pen: _________ Insulin injection: _____ Insulin pump: _______ Insulin to be

administered by: Staff___ Student___

Other medication: ________________ Glucagon kit In Health Room:______ With student:________ Other:______________ Blood Sugar to be

Checked by: Staff____ Student_____________

Target range:____-____ Student is able to

recognize risk factors for onset of elevated or low blood sugar.

Yes _____ No____

Risk for injury related

to development of acute complications of hypo or hyperglycemia.

Knowledge deficit

related to disease process and emergency interventions related to hypo/hyperglycemia.

Student will maintain

a normal blood glucose level throughout the school day as per target range on DMMP.

Student will notify

staff/nurse if displaying signs and symptoms of hypo- or hyperglycemia.

Student will learn and

practice self-management skills including blood glucose monitoring, carb counting & insulin administration.

Staff will recognize

signs/symptoms of hypo/hyperglycemia and verbalize understanding of emergency intervention in accordance to ECP.

Nurse will reinforce

diabetes education as per DMMP and appropriate for age level: blood glucose monitoring, carbohydrate counting, and insulin administration.

Nurse will educate

staff on recognizing signs and symptoms of hypo/hyperglycemia and provide appropriate response to the situation.

Nurse will educate

staff on the administration of Glucagon injection, in the event of severe hypoglycemia.

Student will be an

active participant in diabetes regimen.

Staff and student will

show proficiency operating the blood glucose meter.

Staff and student will

understand signs and symptoms and intervention for hypo/hyperglycemia.

Staff will understand

how and when to administer glucagon.

Name and date of staff members instructed: Classroom Teacher(s) Special Area Teacher(s) Administration Support Staff Reviewed with parent/guardian, Name: in person by phone. Must make no less than two attempts to contact parents/guardian: ___________ __________ ECP Completed. Date 1 Date 2 RN signature: Date:

DOH-Broward N/71 09/16 This plan is in effect for the current school year and summer school as needed.


Emergency Care Plan

School Year 20__- 20__.

Allergies:

Student’s Name: DOB: Age: Parent/Guardian: Contact #: Secondary Emergency Contact/Relationship: Contact #: Healthcare Provider: Contact #:

Diabetes – Hyperglycemia Causes of Hyperglycemia

Too little insulin or other glucose lowering medication Too much food intake Decreased physical activity Illness, infection and or injury or emotional stress Insulin Pump malfunction

The onset of Hyperglycemia happens

over several hours or days and may progress rapidly

Has the student experienced Hyperglycemia before? Yes No Most recent date: __________.

What were his/her symptoms at the time of the event? Hyperglycemia Signs and Symptoms

Please check what applies Increased thirst and or dry mouth Frequent or increased urination Change in appetite, nausea or vomiting Blurry vision Fatigue, lethargy Other:__________________

Actions for Treating Hyperglycemia

• Notify School Nurse or Trained Personnel as soon as

you observe symptoms • Check blood glucose level. The ideal target range for

this student is _______ - ________ • Give student water to drink (nothing with

sugar/fructose) • Accompany student to Health Room

Ongoing Evaluation and Care for Hyperglycemia

• Recheck blood glucose every 1-2 hours to determine if it

is decreasing to target range of ______-_______mg/dL. • Check urine or blood for ketones if blood glucose levels

are greater then: _________mg/dL • If student uses a pump, check to see if pump is

connected properly and functioning • Review student’s medication administration, food and

liquid intake and activity for the last 24 hours • Give extra water or non-sugary drinks (no fruit juices) • Allow free and unrestricted access to the restroom. • Restrict participation in physical activity • Notify parents / guardian

Hyperglycemia Emergency

• If student does not respond to treatment and blood

glucose is still above target range • If student is displaying any of the following: extreme

thirst, nausea and/or vomiting, severe abdominal pain, weak or depressed level of consciousness

• Call 911 • Notify parents/guardian • Notify Healthcare Provider • Stay with student till EMT arrives

Reviewed with parent/guardian: Name: in person by phone.

ECP distributed to staff on a need to know basis. Personnel training date:

Trained Personnel: Trained Personnel:

RN signature: Date:

Exhibit 4A

DOH-Broward N/63 09/16 This plan is in effect for the current school year and summer school as needed.


Emergency Care Plan


Allergies: Student’s Name: DOB: Age: Parent/Guardian: Contact #: Secondary Emergency Contact/Relationship: Contact #: Healthcare Provider: Contact #:

Diabetes – Hypoglycemia

Causes of Hypoglycemia

• Too much insulin • Missing or delaying meals or snacks • Not eating enough foods (carbohydrates) • Getting intense or unplanned physical activity • Being ill, particularly with gastrointestinal illness

• Does the student have Glucagon ordered by

Healthcare Provider? Yes No, if yes, location of Glucagon: ________________________________

Trained personnel to administer Glucagon as ordered and Call 911

• CALL 911 • Special Instructions:

____________________________________ ________________________________________

Has the student experienced Hypoglycemia before? Yes No, most recent date:__________ What were his or her symptoms at the time? Please check below.

Hypoglycemia Signs and Symptoms

Shaky or jittery Pale or sweaty Thirsty and/or hungry Headache, blurry vision Dizzy, confused, or disoriented Change in behavior, irritable, nervous or combative Weak, sleepy or lethargic Other:__________________________________

Actions for Treating Hypoglycemia

• School Nurse or Trained Personnel should come to the classroom to assist student. Always stay with student.

• Check blood glucose level. Ideal blood glucose level for this student is _______-_______

• Give student a quick acting glucose product such as: ___________________________________________

• Contact the student’s parents/guardian • Other instructions: ___________________________ • ____________________________________________

Ongoing Evaluation and Care for Hypoglycemia

• Recheck blood glucose levels every 10-15 minutes • Repeat quick acting glucose product or fruit juice or soda

Treatment for Severe Hypoglycemia

• Position the student on his or her side • Do not attempt to give anything by mouth • If student is unable to eat or drink, unresponsive or

having convulsions: Administer Glucagon injection as ordered by the Healthcare Provider

• While treating, have another person CALL 911 • Notify parents / guardian of current situation • Call student’s Healthcare Provider • Stay with student until EMT arrives

The onset of Hypoglycemia happens quickly and may progress rapidly.


ECP Distributed to staff on a need to know basis. Personnel training date: ______________________________

Trained Personnel: _________________________________ Trained Personnel:

RN signature: Date:

Exhibit 4B

DOH-Broward N/64 09/16 This plan is in effect for the current school year and summer school as needed. Exhibit Page 7 of 66


Allergies: Student’s Name: DOB: Age: Parent/Guardian: Contact #: Secondary Emergency Contact/Relationship: Contact #: Name of Healthcare Provider: Contact #:

In Case of EMERGENCY Call 911 SEIZURE DISORDER, Please check all that apply

Assessment Data Nursing Diagnosis Goals Nursing Interventions Expected Outcome

Student has history of

seizure disorder. Last episode(date and duration), triggers and description of seizure: ___________________

___________________ ___________________

___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Medication Orders from

Physician: Yes_____ No______

Based on seizure history: Risk of injury related to seizure activity. Yes No Potential for aspiration related to seizure activity. Yes No Importance of

compliance with meds.

Decreased

self-esteem related to chronic illness.

Train staff to identify

and respond to seizure.

Prevent injury during

seizure. Prevent aspiration

during seizure. Student receives

medication as ordered by Healthcare Provider to reduce risk of seizure activity.

Student will have

increased knowledge base of disease process regarding prevention of seizure with medication compliance and recognizing the onset of a seizure to prevent injury.

Train staff to protect,

support and prevent injury.

Position child on

his/her side to prevent aspiration. Call for help.

Maintain compliance

with medications as ordered by Healthcare Provider.

Increased self esteem

by providing education and support for student to talk about issues related to illness.

Student will not

experience seizure. Staff will be well

trained to provide care and support to the student.

Staff will identify

seizure and follow ECP and call for help.

If a seizure occurs

the student will not experience injury or aspirate during the seizure.

Name and date of staff members instructed:

Classroom Teacher(s)

Special Area Teacher(s)

Administration

Support Staff


Must make no less than two attempts to contact parents/guardian: _________ __________ ECP Completed.

Date 1 Date 2

RN signature: Date:

Exhibit 5

DOH-Broward N/66 08/16 This plan is in effect for the current school year and summer school as needed Exhibit Page 8 of 66

Emergency Care Plan


Allergies: Student’s Name: DOB: Age: Parent/Guardian: Contact #: Secondary Emergency Contact/Relationship: Contact #: Healthcare Provider: Contact #:

Seizure Disorder

Basic Seizure First Aid

If you see this:

Symptoms of a seizure episode may include any or all of these. • Temporary confusion, staring spell • Convulsion lasting longer than ____ minutes • Uncontrollable jerking movements of the arms and legs • Loss of consciousness or awareness • Pale, clammy, nail beds pale/bluish gray in color • Rapid heart rate or changes in breathing patterns • Other symptoms:

____________________________________________________________________________________________________________________

__________________________________________________________

Do this:

• Stay calm. Remove bystanders • Keep airway clear, turn on side

if possible, nothing in mouth • Keep safe, remove objects, do

not restrain • Time, observe, record what

happens • Stay with student until

recovered from seizure

Seizure Emergency Action Steps

• Call 911 Inform EMS that you have a Seizure Emergency. They will ask the student’s name, age, physical symptoms and what medication he/she takes daily and what medication has been administered for this event.

• Notify School Nurse or Trained Personnel (see below). • Administer medication as ordered.

Location of medication: Clinic, Classroom, Self carries • Medication:_____________________ • Dose:___________________________ • Route:___________________________ • Time Administered: ________________ • Call parent or guardian (listed above)

Other instructions:_________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Reviewed with parent/guardian: in person by phone. Name:

ECP Distributed to staff on a need to know basis. Personnel training date: _________________________

Trained Personnel: __________________________ Trained Personnel: ______________________________

RN signature: Date:

Exhibit 5A

DOH-Broward N/67 09/16 This plan is in effect for the current school year and summer school as needed Exhibit Page 9 of 66


Exhibit 6

Allergies: Previous episode of Anaphylaxis: Describe Incident: Student’s Name: DOB: Age: Parent/Guardian: Contact #: Secondary Emergency Contact/Relationship: Contact #: Name of Healthcare Provider: Contact #:

In Case of EMERGENCY Call 911

Anaphylaxis / Allergy, Please check all that apply Assessment Data Nursing Diagnosis Goals Nursing Interventions Expected Outcome

Student has Medication/ Treatment Authorization. Yes_____ No______ Events which may trigger an allergic response: ______________________ ______________________ ______________________ Symptoms of student’s allergic response (check those that apply): Itching or swelling of the

mouth, lips, tongue, face, or extremities.

Cough, tightness in throat, difficulty swallowing, wheezing, shortness of breath, difficulty breathing.

Increased heart rate, weak pulse, dizziness, feeling faint.

Skin redness, itchy hives/rash, pain at site of exposure.

Nausea, vomiting, abdominal cramps, diarrhea.

Student is able to recognize risk factors for onset of anaphylaxis. Yes _____ No_____

Potential for severe

allergic reaction or life threatening episode.

Knowledge Deficit

related to disease process.

Student will maintain

optimum health and safety necessary for learning.

Student and staff will

understand the disease process of allergies/anaphylaxis and emergency interventions.

Staff will be educated

on the signs and symptoms of the early stages of anaphylaxis.


on emergency procedures for anaphylaxis.

Student will have an

Emergency Care Plan in place for severe allergy/anaphylaxis.


on use of Epinephrine.


on allergens and substances that can cause anaphylaxis and ways to avoid allergens.

All substances

causing anaphylaxis will be avoided and student will have an incident free learning experience.


the emergency procedures and demonstrate competency regarding use of the Epinephrine.

Student will

participate in collaboration which facilitates optimum health and safety necessary for learning.


the early stages of anaphylaxis and follow protocol to treat.

Name and date of staff members instructed:

Classroom Teacher(s) Special Area Teacher(s) Administration Support Staff Reviewed with parent/guardian: Name: in person by phone. Must make no less than two attempts to contact parents/guardian: ECP Completed Date 1 Date 2 RN signature: Date:

This plan is in effect for the current school year and summer school as needed. DOH-Broward N/62 09/16


School Year 20___- 20___

Allergies/triggers: nuts soy products wheat shellfish insects other: Date of previous episode of anaphylaxis: Describe Incident:

Student’s Name: DOB: Age: Parent/Guardian: Contact #: Secondary Emergency Contact/Relationship: Contact #: Healthcare Provider: Contact #:

Anaphylaxis

Does the student have Asthma? Yes (increased risk for severe reaction) No

Symptoms of an allergic reaction may include any/all of the following:

If you see this: (Circle those that apply)

Act Quickly! Follow the Medication / Treatment Authorization:

(Check all that apply)

• Itching or swelling of lips, tongue or mouth.

• Hoarse, coughing, tightness in throat, difficulty

swallowing, wheezing, shortness or difficulty breathing,

increased heart rate, weak pulse.

• Redness, itchy hives, itchy rash, swelling of face and

extremities.

• Nausea, vomiting, abdominal cramps, diarrhea.

• Dizziness, feeling faint, pain at site.

Comment: ___________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________

Treatment should be initiated with symptoms Antihistamine ordered Epinephrine Auto Injector, follow instruction on devise Other:______________________________________ Medication in clinic Student self carries Other instructions:____________________________

• Call 911 after using Epinephrine Auto-Injector. • Call School Nurse or Trained Personnel. • Call parent/guardian (listed above). • Stay with student at all times. Stay calm. • Monitor student’s reaction, respiratory and heart rate • Special Instructions:_____________________________ _____________________________________________

Call 911- The severity of symptoms can change quickly It is important that treatment is given immediately in the order that places the student’s safety first.


ECP distributed to staff on a need to know basis. Personnel training date: ___________________________

Trained Personnel: ______________________________ Trained Personnel: ___________________________________

RN signature: Date:

Exhibit 6A

DOH-Broward N/55 09/16 This plan is in effect for the current school year and summer school as needed. Exhibit Page 11 of 66

THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDACoordinated Student Health Services, 1400 NW 14 Court, Fort Lauderdale, FL 33311

AUTHORIZATION FOR MEDICATION: Prescription or Over-the-Counter Medication Student's Name: Date of Birth: Grade: School: _______________________________Phone #: Fax#: _______________ *********************************************************************************************************************************** Allergies: ___________________________________________________________________________ Diagnosis: ___________________________________________________________________________

MEDICATION DOSAGE & ROUTE

FREQUENCY SPECIFIC TIMES

SPECIAL INSTRUCTIONS/ SIDE EFFECTS

List any emergency precautions / health emergencies that should be anticipated for this student; e.g. allergy triggers, diabetic reactions, etc.) : _______________________________________________________________________________ _______________________________________________________________________________________There are no extraordinary emergency medical services available at school. Since only CPR and first aid are available until 911 arrive, is this adequate for student survival? YES NO, IF "NO", specifies: _______________________________________________________________________________________ *********************************************************************************************************************************** _________________________________________ _______________________________________ Physician’s Name (Printed) Physician’s Signature _________________________________________ _______________________________________

Physician’s Telephone & Fax Numbers _________________________________________ _______________________________________ Physician’s Office Address Date Completed *********************************************************************************************************************************** This information will be obtained by School Board District Personnel

PARENTAL PERMISSION FOR MEDICATION (TO BE COMPLETED BY THE STUDENT’S PARENT / GUARDIAN)

Student's Name: _______________________Date of Birth: ______________Grade:

I grant the principal or his / her designee the permission to assist or perform the administration of each medication to or for my child during the school day, including when he/she is away from school property for official school events. If my child has been authorized by his/her physician to self-administer their medication(s), I grant permission for my child to self-administer their medication at school and when they are away from school property for official school events. In the event that my child is unable to self-administer their medication, I give permission for the principal/designee to perform the administration of the prescribed medication.

NOTE: • Medications must be supplied in the original container. Ask the pharmacist to divide the medication into two completely

labeled containers, providing one for home and one for school. • School personnel may administer only medications authorized by a physician.• It is your responsibility to notify the school when there is a change in medication regimen.

___________________________________ _____________________________________________ Parent / Guardian Name (Printed) Signature of Parent / Guardian

___________________________________ _____________________________________________ Date Signed Home Phone Number

___________________________________________________________ Work/Cell Phone Number (Include Ext. if any)

Form #2240 Rev. 8/15

Exhibit 7

Page 1 of 2Exhibit Page 12 of 66

THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDACoordinated Student Health Services, 1400 NW 14 Court, Fort Lauderdale, FL 33311

AUTHORIZATION FOR TREATMENT Student's Name: Date of Birth: Grade: School: Phone #: Fax#: *********************************************************************************************************************************** Diagnosis: ________________________________________________ Allergies: _______________________________ TREATMENTS DURING SCHOOL HOURS Treatment Plan: _______________________________________________________________________________________

PROCEDURE TYPE MEDS / FEEDING

AMOUNT FREQUENCY

SPECIFIC TIMES RATE / FLOW

Catheterization Feedings G-Tube J-Tube

NG-Tube Special ________ Suctioning Oropharynx

Tracheostomy Deep Surface

Tracheostomy Tube Replacement Care (Cleaning)

CPT Oxygen /Misting Ventilator Nebulizer Tx Pulse Oximeter

Are any of the above procedures required for emergency care? YES NO, IF "YES", specify: _______________________________________________________________________________________List any procedures the student has been trained to perform __________________________________________ List any limitations / precautionary measures that should be considered; e.g. physical education, outdoor activities, transporting, lifting, moving, special devices / equipment: ___________________________________________ _______________________________________________________________________________________ List any emergency precautions / health emergencies that should be anticipated for this student; e.g. allergy triggers, diabetic reactions, etc.) : ____________________________________________________________________ _______________________________________________________________________________________There are no extraordinary emergency medical services available at school. Since only CPR and first aid are available until 911 arrive, is this adequate for student survival? YES NO, IF "NO", specifies: _______________________________________________________________________________________

_________________________________________ _______________________________________ Physician’s Name (Printed) Physician’s Signature

______________________________________________________ ____________________________________________________ Physician’s Telephone & Fax Numbers

_________________________________________ _______________________________________ Physician’s Office Address Date Completed *********************************************************************************************************************************** This information will be obtained by School Board District Personnel

PARENTAL PERMISSION FOR TREATMENT (TO BE COMPLETED BY THE STUDENT’S PARENT / GUARDIAN)

Student's Name: _______________________ Date of Birth: ______________Grade: _______________ I grant the principal or his / her designee the permission to assist or perform the administration of each treatment/procedure to or for my child during the school day, including when he/she is away from school property for official school events. If my child has been authorized by his/her physician to self-administer their medication(s), I grant permission for my child to self-administer their treatment at school and when they are away from school property for official school events. In the event that my child is unable to self-administer their treatment, I give permission for the principal/designee to perform the administration of the prescribed treatment. NOTE: school personnel may administer only treatments authorized by a physician. It is your responsibility to notify the school when there is a change in treatment regimen.

___________________________________ _____________________________________________ Parent / Guardian Name (Printed) Signature of Parent / Guardian _______________________________ __________________________ ____________________________________________ Date Signed Home Phone Number Work/Cell Phone Number (Include Ext. if any)

Exhibit 7

Page 2 of 2


STUDENT MEDICATION LOG Allergies

Student's Name: DOB: School: Hm Rm Teacher

Doctor: Phone # Fax #: Diagnosis :

Special Instructions: Side Effects: Month/Year:

MEDICATION

NAME DOSAGE

TIME TO BE GIVEN ROUTE

* Record the amount of Medication received (i.e. # of pills, amount of liquid) with each initial receipt in the“Notes” Section on the Reverse

* Record Time Medication was given (or Reason not given) and Initials in the appropriate boxes* If medication is not given, please use one of the following abbreviations to indicate the reason why:

A-absent O-out of medication F-field trip D-discontinued R-refused DW-dose wasted ER-early release day V-vacation/school closed S-Other and Provide explanation in the “Notes” Section on the Reverse side

Date AM

Initials PM

Initials AM

Initials PM

Initials AM

Initials PM

Initials AM

Initials PM

Initials

Signature/Initials/Date for each week.

Signature/Initials: Signature/Initials:

Exhibit 8


STUDENT MEDICATION LOG NOTES

DATE TIME DATE TIME

DOCUMENTATION OF RECEIPT OF MEDICATIONS

DATE RECEIVED

MEDICATION (Name and dosage)

AMOUNT (# of Tablets or amount

of Liquid)

PARENT/GUARDIAN SIGNATURE

RECEIVED BY (SIGNATURE)

. 9/27/10 OP 151-O-PHN 45 Attachment 32 2

Exhibit 8


THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA HEALTH EDUCATION SERVICES 754-321-2272 Diabetes Medication/Treatment Authorization

Student’s Name: ___________________________________ Date of Birth: _________ Date:

School Name: Grade_______ Homeroom

CONTACT INFORMATION

Parent/Guardian #1: Phone Numbers: Home

Work Cellular/Pager

Parent/Guardian #2: Phone Numbers: Home

Work Cellular/Pager

Physician/Healthcare Provider: Phone Number _________________

Other Emergency Contact: Phone Number: Home____________________

Relationship: Work/Cellular/Pager

EMERGENCY NOTIFICATION: Notify parent/guardian of the following conditions If unable to reach parent/guardian: Notify healthcare provider and emergency contact listed above a. Loss of consciousness or seizure (convulsion) immediately after Glucagon given and 911 called.b. Blood sugars in excess of mg/dl c. Positive urine ketones.d. Abdominal pain, nausea/vomiting, diarrhea, fever, altered breathing, or altered level of consciousness.

BLOOD GLUCOSE MONITORING: At school: Yes No Student has been trained by Healthcare Professional Yes No To ordinarily be performed by student: Yes No Type of Meter:

Time to be performed: Before breakfast Before PE/Activity Time Mid-morning (before snack) After PE/Activity Time Before lunch Mid-afternoon Dismissal As needed for signs/symptoms of low/high blood glucose

Place to be performed: Clinic/Health Room Classroom Other

OPTIONAL: Target Range for blood glucose: __________ mg/dl to _________mg/dl

INSULIN INJECTIONS DURING SCHOOL: . Yes � No Student has been trained by Healthcare Professional � Yes � No If yes, can student determine correct dose? � Yes � No Draw up correct dose? � Yes No Give own injection? � Yes � No Insulin Delivery: Syringe/Vial � Pen � Pump (If pump worn, use “Insulin Pump Medication/Treatment Plan”)

Standard daily insulin at school: � Yes � No

Type: Dose: Time to be given:

________ ___________ _________________

________ ___________ _________________

Calculate insulin dose for carbohydrate intake: � Yes � No

If yes use Regular Humalog Novolog

_________#unit(s) per __________grams Carbohydrate

Add carbohydrate dose to correction dose

OTHER ROUTINE DIABETES MEDICATIONS AT SCHOOL: Yes

Name of Medication Dose

EXERCISE, SPORTS, AND FIELD TRIPS: Blood glucose monitoring and snacks as indicated. Easy access to sugar-free liquids, fast-acting carbohydrates, snacks,Child should not exercise if blood glucose level is below m

Exhibit 9

Exh

Correction dose of Insulin for High Blood Sugar: Yes No

If yes, Regular Humalog ___Novolog Time to be given_____

Time to be given:

Determine dose per sliding scale below: Use formula

Blood sugar:_______Insulin Dose:__________ Blood Glucose -

Blood sugar:_______Insulin Dose:__________ _________ ÷

Blood sugar:_______Insulin Dose:__________ _________ =

Blood sugar:_______Insulin Dose:__________ units of insulin

No

Time Route Possible Side Effects

and blood glucose monitoring equipment. g/dl OR if

ibit Page 16 of 66

KieswetterCL

Text Box

OP 151-O-PHN 51 Attachment 1

Diabetes Medication/Treatment Authorization – Page 2 MANAGEMENT OF HIGH BLOOD GLUCOSE ( over ________ mg/dl)

4Usual signs/symptoms for this student: Indicate treatment choices: Increased thirst, urination, appetite Sugar-free fluids as tolerated Tired/drowsy Check urine ketones if blood glucose over mg/dl Blurred vision Notify parent if urine ketones positive. Warm, dry, or flushed skin May not need snack: call parent

__ Nausea/Vomiting __ Frequent bathroom privileges Other See “Insulin Injections: Extra Insulin for High Blood Glucose”

Other

MANAGEMENT OF LOW BLOOD GLUCOSE (below mg/dl)

4Usual signs/symptoms for this child Indicate treatment choices: Change in personality/behavior If student is awake and able to swallow, Pallor give _____ grams fast-acting carbohydrate such as: Weak/shaky/tremulous _ 4oz. Fruit juice or non-diet soda or Tired/drowsy/fatigued _ 3-4 glucose tablets or Dizzy/staggering walk __ Concentrated gel or tube frosting or Headache _ 8 oz. Milk or Rapid heartbeat __ Other Nausea/loss of appetite Clammy/sweating Retest Blood Glucose 10-15minutes after treatment Blurred vision Repeat treatment until Blood Glucose over 80mg/dl Inattention/confusion Follow treatment with snack of Slurred speech if more than 1 hour till next meal/snack or if going to activity (i.e. P.E. or recess) Loss of consciousness Other Seizures Other________________________ If student is vomiting or unable to swallow, administer Glucose gel or Glucagon

(See below for specific directions)

Physician /Healthcare Provider Signature: Date:

Physician/Healthcare Provider Name __________________________________________Phone Number_______________________________

I grant the principal or his/her designee or a licensed nurse (RN/LPN) permission to assist with or perform the administration of each prescribed medication, including insulin either by injection or pump, and treatments/procedures for my child during the school day. This includes when he/she is away from school property for official school events. I have reviewed, understand and agree with the medications/treatments prescribed by the physician/healthcare provider on this form. It is my responsibility to notify the school if there is a change in the medication/treatment plan prior to its expiration date.

Parent/Guardian Signature: Date:

LOCATION OF SUPPLIES/EQUIPMENT: To be completed by school health personnel. Blood glucose testing equipment: Insulin administration supplies:

Glucagon emergency kit: Glucose gel: Ketone testing supplies:

Fast-acting carbohydrate: Snack foods: _____3/04

Exhibit 9 HES 1/02

IMPORTANT!! If student is unconscious or having a seizure, presume the student is experiencing a low blood glucose level and:

Call 911 immediately and notify parents / guardian.

Glucagon ____mg IM (injection) should be given by trained personnel

Glucose gel 1 tube can be administered inside cheek and massaged from outside while waiting for help to arrive, or during administration of Glucagon by any trained staff member at scene.

Student should be turned on his/her side and maintained in this “recovery” position till fully awake.

Comments _____________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________


KieswetterCL

Text Box

OP 151-O-PHN 51 Attachment 1

KieswetterCL

Text Box

Daily Diabetes Log

Student’s Name___________________________________ School_________________________________Week of_________________

Doctor_____________________________________Phone # ___________________________ Fax # ______________________________ TYPE OF INSULIN GIVEN_______(H = Humalog R = Regular NP = NPH U = Ultra Lente) Given by (circle) PUMP INJECTION For Pump, give reason for insulin administration: B = Bolus C = Correction Dose A = absent V = no school S = other

REMEMBER ADMINISTER INSULIN ONLY AT TIMES ORDERED DAY/DATE MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY TIME BLOOD SUGAR # CARBS IN GMS INSULIN (# units) SITE Initials TIME BLOOD SUGAR # CARBS IN GMS INSULIN (# units) SITE Initials TIME BLOOD SUGAR # CARBS IN GMS INSULIN (# units) SITE Initials TIME BLOOD SUGAR # CARBS IN GMS INSULIN (# units) SITE Initials Signature Signature Rev. 6/9/11

Exhibit 10


Daily Diabetes Log

DATE TIME Initials

DATE RECEIVED

MEDICATION (Name and dosage)

AMOUNT PARENT/GUARDIAN SIGNATURE

RECEIVED BY (School designee signature)

HES 4/05 PAGE 2 Rev 6/9/11

Exhibit 10


Table 4: Services provided by1 Non-Medication Visits 1 911 Services 1 Medications (oral) 1 R.N. / A.R.N.P. 1 Abuse Registry2 Medication Visits 2 Emergency Room 2 Medications (other) 2 L.P.N. 2 Dental Care

TOTAL: 3 Returned to Class 3 Medications (Inhaler) 3 Health Support Tech 3 Guidance Counseling4 Sent Home 4 Medications (Injection) 4 Clerical Support staff 4 Healthy Start5 Other: 5 Insulin Adminstration 5 Kidcare

TOTAL: 6 Intravenous Treatments 6 Medical / Nursing Care7 Mental Health Coun.

Complex Procedures 8 No Referral7 Oxygen cont./intermittent 9 Nursing Assessment8 Carbohydrate Counting 10 Social Work Services9 Catheterization 11 Subst. Abuse Coun.10 Ostomy care 12 Parent11 Electronic Monitoring12 Tube/PEG Feeding13 Glucose Monitoring14 Specimen Collect./testing 15 Tracheostomy Care16 Ventilator Dependent Care

17 First Aid18 Other

Table 1: Total Visits Table 5: Referral To Table 2: Outcome Disposition

Daily Summary Log

School Name/Level:_____________________________ Health Room Staff:___________________________ Date:__________ DAU #:________

Table 3: Procedure

Codes for Completing the Daily Clinic Log

DOH-Broward N-184a

Exhibit 11


NUMBER OF STUDENTS

Ventilator Dependant CareOther Procedure-Specify:Other Procedure-Specify:Other Procedure-Specify:

MEDICATIONS

Medications/Other InjectionsMedication/IntravenousMedications/Inhaler (or nebulizer)

Colostomy, Ileostomy, Urostomy, Jejunostomy Care (site care)Electronic Monitoring (cardiac, oximetry,

DOH-Broward, School Health Services, Unduplicated Log for Medications and Procedures

Subtotal:

Oxygen Continuous or IntermittentJ, PEG, NG Tube Feeding

Specimen Collection or Testing

PROCEDURES

Insulin Administration

Medications/Oral (by mouth)

Carbohydrate Counting

Total:

Medications/NasalOther Route-Specify:Other Route-Specify:Other Route-Specify:

Glucose MonitoringCatheterization

Subtotal:

Tracheostomy Care

Exhibit 12


Revised 09.2013 Page 1 OP 151-O-PHN 45 Attachment 22

# STUDENTS NAME MEDICATION/PRODECURE1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

DOH-Broward, School Health Services · UNDUPLICATED LOGNumber of Students Needing Medications and/or Procedures During 20__ - 20___.

Exhibit 12


School:______________________________Health Room Staff:__________________________Date:_______DAU #:__________

Table 1.a Table 1.b Table 2 Table 3 Table 4 Table 5

Time In Last Name First Name Grade Non-

Medication MedicationOutcome

Disposition ProcedureService

provided by Referral To Time Out

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

Total: Total: Total:

OP 151-O-PHN 45FDOH-Broward 184a, Rev. 9/2011

Daily Clinic Log Exhibit 13


Table 2: Outcome dispositon Table 4: Services provided bya Non-Medication Visits 1 911 Services 1 Medications (oral) 1 R.N. / A.R.N.P. 1 Abuse Registryb Medication Visits 2 Emergency Room 2 Medications (other) 2 L.P.N. 2 Dental Care

TOTAL: 3 Returned to Class 3 Medications (Inhaler) 3 Health Support Tech 3 Guidance Counseling4 Sent Home 4 Medications (Injection) 4 Clerical Support staff 4 Healthy Start5 Other: 5 Insulin Adminstration 5 Kidcare

TOTAL: 6 Intravenous Treatments 6 Medical / Nursing Care7 Mental Health Coun.

Complex Procedures 8 No Referral7 Oxygen cont./intermittent 9 Nursing Assessment8 Carbohydrate Counting 10 Social Work Services9 Catheterization 11 Subst. Abuse Coun.10 Ostomy care 12 Parent11 Electronic Monitoring12 Tube/PEG Feeding13 Glucose Monitoring14 Specimen Collect./testing 15 Tracheostomy Care16 Ventilator Dependent Care

17 First Aid18 Other

DOH-Broward N/184b

Table 1: Total Visits Table 5: Referral To

Monthly Summary Log

School Name/Level:_____________________________ Health Room Staff:___________________________ Date:__________ DAU #:________

Table 3: Procedure

Codes for Completing the Monthly Clinic Log

Exhibit 14


School Monthly Data Collection Form by Grade LevelSchool: DAU #

Month/Year: Grade Level:

Description HMC PC #

Pediculosus or Scabies screening, new 0571 34

Pediculosus or Scabies screening, repeat 0571 34

Pediculosus or Scabies screening, completed 0571 34

Student evaluation/intervention by a para-professional 4000 34

Student encounter by an LPN 4050 34

Physical activity referral 4700 34

RN nursing assessment / counseling 5000 34

RN nursing assessment / counseling postpartum 5024 34

Medication Administration 5030 34

First Aid Administration 5031 34

Complex Medical Procedures 5032 34

Immunization Follow-Up 5033 34

Counsultation with School Health staff / parent 5051 34

ESE staffing / screening 5052 34

Student Heatlh Care Plan developed 5053 34

Licensed Social Worker intervention 6030 34

Paraprofessional follow /up 6500 34

Health education, number of classes given 8020 34

Health education, number of participants 8020 34

Child specific training of school staff by RN 8080 34

Prepared by:

Name/Title

Signed Date

*Note section above is not by grade level *Grade level is only for screenings

Agency

Exhibit 15


2017 Annual School Health Report For:_______________

For in-kind hours and value of in-kind services, put annual totals (not weekly totals) and use only numbers (no text characters (i.e., per week).

Adult Education

Basic Medical Services

Case Management

Child Protective Services

Community Education

Counseling Abused Children

Counseling High-Risk Children

Counseling High-Risk Parents

Delinquency Counseling

Dental Services

Economic Services

Healthy Start/Healthy Families

Job Placement Services

Mental Health Services

Nutritional Services

Parenting Skills Training

Resource Officer

School Health Nursing Services

Social Work Services

TOTALS 0 0

All Other

Substance Abuse Counseling

TANF programs (job training)

PART III: FULL SERVICE SCHOOLS

ANNUAL Total Number of Donated In-Kind Hours

ANNUAL Estimated Value of In-Kind ServicesType of Service

III-A: IN-KIND SERVICES PROVIDED IN FULL SERVICE SCHOOLS BY COMMUNITY AGENCIES

Exhibit 16


School Health Room Review Sheet County: School: _Principal: _Date: Basic Comprehensive Full Service Number of Students: Reviewer:

Legend: (F.S.)-Florida Statutes, (F.A.C)-Florida Administrative Code, (FSHAG)-Florida School Health Administrative Guidelines, (SREEF)-State Requirements for Existing Educational Facilities, (GS7)-General Records Schedule, (MUSRM)-Medication Use In Schools Resource Manual, (UAP)-Unlicensed Assistive Personnel, (AED)-Automated External Defibrillator, (ES)-Elementary School, (MS)-Middle School, (HS)-High School , (MAR)-Medication Administration Record, (RN)- Registered Nurse, (LPN)-Licensed Practical Nurse, (UAP)-Unlicensed Assistive Personnel, (FSS)-Full Service School

I. Personnel

Health Room staffed full time: Yes No If no, # hours/days staffed: # Designated School Staff:

# of Health Room Staff by type: RN(s): LPN(s): UAP(s):

RN supervisor: Frequency on site: FSHAG Sect. III, 1-1-3. II. Health Room/Clinic Facilities

Reference Items for Review Yes No Comments (A) Clinic

Health treatment protocols for management of chronic and complex conditions, and emergency procedures are readily available, including communicable disease control protocols Administrative protocols and references are available

Medication Administration Policy and Procedures s. 1006.062 (1), F.S.Ch. 64B9-14, F.A.C.

School District Medication Policy available onsite & addresses:

″ School personnel designated by principal to assist in medication administration (list of designated staff available)

″ Annual training of designated personnel with verification of delegate’s understanding of assignment present and;

″ Verification of periodic monitoring and supervision of delegated tasks present

FSHAG III 4-3 Medication Errors – with specific documentation required for reporting medication errors and:

″ Medication Errors - notify supervising school nurse, school administrator, parent, prescribing MD, poison control if wrong student received medication

Clinic Log GS7 - Item 120, FSHAG IV 18-5, Ch. 64F-6.005(1)(e), s. 1002.22, F.S.

Standardized clinic log (paper or electronic): student name, date, time in, reason for clinic visit, nurse/UAP, time out, disposition. Clinic log concealed to protect student confidentiality.

Clinic Physical Facilities s. 381.0056(5b & 6c), F.S,FSHAG IV 21 2-4, SREEF 5-5 (13)(g) Pg. 35

School has adequate physical facilities for health clinic (reception/office/storage/toilet room/bed space present)

SREEF 5-5 13(g)(1)(a & b) Ch. 64E-13.004(6), F.A.C.

Clinic toilet room(s) present: 1 for ES; 2 for MS/HS (1 male, 1 female)

SREEF 5-5 13(g)(1)(c) Clinic toilet room (sinks) have hot (temp ≤ 110◦ F) and cold water SREEF 5-5 13(g)(1d), Ch. 64E-13.004 F.A.C.,

Toilet rooms – functioning exhaust fan vented to exterior

SREEF 5-5 13(g)(2) Clinic bed space (separated for male/female in MS/HS) SREEF 5-5 13(g)(2a) Clean, plastic covered mattress & pillow per bed SREEF 5-5 13(g)(2b) Clean, disposable mats for each patient SREEF 5-5 13(g)(3), (h)(3) Visual supervision of beds from reception area/office/nurses station SREEF 5-5 13(h)(4) FSHAG III-4-4 Pg. 36

(FSS) Lockable storage room with doors operable from the inside (for refrigerator, files, equipment, and supplies)

SREEF 5-5 13(h)(5) (FSS) Data outlets for computer hookups & networking SREEF 5-5 h)(5) (FSS) Additional electric outlets for hearing/vision testing machines SREEF 5-5 13(h)(6) (FSS) Direct access to clinic from exterior SREEF 5-5 13(h)(6) (FSS) Direct access to from interior or connected by covered walk

Exhibit 17


SREEF 5-513(h)(7) (FSS) Designated parking adjacent to clinic (1 disabled accessible)

(B) Emergency Supplies/Procedures Ch. 64F-6.004(1), F.A.C. Policies/Procedures for management of health emergencies in clinics,

schools, etc. Ch. 64F-6.004(2) (3), F.A.C. FSHAG III 7-3

Current First Aid/CPR certification-health room staff & 2 additional school staff-copy in health room or office

Ch. 64F-6.004(5)(6), F.A.C. FSHAG III-4-1,2 FSHAG III-7-3&4 Ch. 64E-13.004 (11), F.A.C.

First Aid supplies (band aids, gauze squares, elastic roller gauze, cotton balls, cotton tipped applicators, tape, gloves, etc.), first aid kit for use on other parts of campus, and emergency equipment are available and none are expired.

Ch. 64F-6.004 (1b)(2)(3), F.A.C., FSHAG III-7

Locations of emergency supplies/AED/certified First Aid/CPR staff posted - health room, cafeteria, gym, etc.

s. 1006.165(1), F.S.,SREEF-5- 5 (10)(k)pg. 29, FSHAG IV, 21-3, Ch. 64J- 1.023, F.A.C.

AED required at schools in the Florida Athletic Assoc. only. If AED present, it is maintained in safe, secure, and usable condition. Location is registered with local EMS.

s. 1006.165(2), F.S.Ch. 64J-1.023, F.A.C.

Persons expected to use AED – documented training/proficiency

III. Medication Administration(A) Medications Reference Items for review Yes No Comments FSHAG III 4-1,2) Medication label (student name, med name, dosage & directions,

times of admin., provider’s name, date (≤ 1yr) s. 1006.062(1)(b-2) F.S. Medications received, counted (initially & refills) - stored in original

container, secured under lock and key when not in use FSHAG III -4-2 OTC Meds labeled student specific s. 499.0121(1)( c )(5)(a-1),F.S.

Medications not expired (if expired meds present, quarantined from usable medications)

s. 499.0121(3a,b), F.S.,MUSRM page 72, FSHAG III 4-4

Medications requiring refrigeration in locked fridge maintained at 35- 45◦F (regularly documented) Assn. for Professionals. in Infection Control (APIC) (36-46)

(B) Medication Administration Record (MAR) FSHAG III 4-5, IV 18-5 MUSRM page 47

Demographics: student name, id, age, dob, grade, photo (if available)

″ Allergies (medication, food, environmental, etc.) ″ Medication: name, dose, route, frequency, time ″ Initials/name/signatures of persons authorized to administer ″ Code (with explanation) for meds not administered

s. 1006.062(1)(b)(1), F.S.,FSHAG III 4-1

Parental permission to administer med, statement of need for med & known student-specific side effects to med

Comments:

Exhibit 17


School: _____________________________________ 20____- 20____ RN Name/Signature: __________________________________________

Student’s name Contact Information

Hea

lth C

ondi

tion

Imm

uniz

atio

n 68

0

Phys

ical

304

0

BMI

Hea

ring

Visi

on

Scol

iosi

s

504

IEP Comments

School Health Record Review Worksheet

Exhibit 18

DOH-Broward N/14 02.2017 Exhibit Page 29 of 66

FTE Week Report

School: _______________________ Agency:______________

Counting School Health Encounters and Services at Your School during 2017 February FTE Week February 6-10, 2017 or other week in February specified by your

County Health Department and/or School District School Health Coordinator.

Count visits & health services to/by regular students, ESE students & students with 504 plans.

(1) Student Visits to the School Health Room (Clinic) Count each time a student comes to the school health room (clinic) or other school location for health services (Medications Received or Self-Administered, Procedures, Counseling, Sick Care, First Aid, Other)

Weekday Monday Tuesday Wednesday Thursday Friday Total Visit Totals

(2) Medications Administered If a student receives more than one medication, count each medication separately.

Weekday Monday Tuesday Wednesday Thursday Friday Total Insulin Administration Medications/Other Injections Medication/Intravenous Medications/Inhaler (or nebulizer) Medications/Oral (by mouth) Medications/Nasal Medication/Other Routes (specify):

Medication/Other Routes (specify):

Medication/Other Routes (specify):

Medications Administered Totals (3) Health Procedures Performed If a student receives assistance with more than one procedure, count each procedure separately.

Weekday Monday Tuesday Wednesday Thursday Friday Total Carbohydrate Counting Glucose Monitoring Catheterization Colostomy, Ileostomy, Urostomy, Jejunostomy Care (care to the site) Electronic Monitoring (cardiac, oximetry, other) J, PEG, NG Tube Feeding Oxygen Continuous or Intermittent Specimen Collection or Testing Tracheostomy Care Ventilator Dependent Care Other Procedure (specify):

Other Procedure (specify):

Other Procedure (specify):

Procedures Performed Totals

Exhibit 19


RN School Visit Log

RN Name: RN Signature: Dates: _____ - _____

Date School Visited Time In

Time out

Total Hours

School Personnel Signature

Exhibit 20

DOH-Broward 01.2017 Exhibit Page 31 of 66

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