Daily Log – Suctioning Tracheostomy
Month/Year: ______
Student Name: / IEP (Y/N) / DOB:Diagnosis: / School Site:
Physician’s Orders or Special Instructions: / Teacher/Grade:
Student ID #:
= Expected Outcome / After the prescribed procedure, the student’s secretions are mobilized and airway is maintained free of secretions.
Student was able to return to daily activities and communicated overall well-being.
= Exception: / Enter additional observations, actions and/or other comments on page 2.
Date / Start Time / End Time / Secretions(1) / Secretions Amount(2) / Secretions Color(3) / Lung Sounds(4)
R L / Outcome Code / Initials
1- t= thin, TH= thick 2- small < 5cc, m=moderate < 10 cc, l=large >15cc 3- p=pink, y= yellow, w=white, g=green, b=brown, c=clear, bl=bloody 4- cl=clear, r= rhonchi, cr=crackles
Daily Log -Suctioning Tracheostomy
Student Name: ______DOB:______Month/Year: ______School Site: ______
Documentation Directions: Person performing assisted feeding service shall:
(1) Enter on chart the date and start/end times care is provided, (2) Note details of the service and Outcome Code & (3) Initial in columns provided.
*School nurse and designated qualified staff should include identifying signatures below only one time.
*If student is absent, note date & write "Absent" on log. If student is present but a daily feeding is not done, indicate on log & explain in comments.
*Nurse supervising the procedure signs in appropriate signature space below. On days nurse is present, he or she notes presence on comment sheet.
*This form shall be attached to Standard Healthcare Procedure and packet shall be filed in the student's confidential or special education record.
Service Provider’s Printed Name: / Signature / Title / InitialsSupervising Nurse’s Name, Signature & Date:
Comments – Suctioning Tracheostomy
*Note additional information about additional action taken, observations, contact with school nurse and/or parent to report problems and outcome.
Date / Start Time / End Time / Comments / Initials