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Healthcare Plan Checklist

Below is a sample checklist. For a printer friendly copy, click here

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 assessment: 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_________