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:
u  Parent Questionnaire/ Forms
u  Other ______
u  Medical/Special Ed Records reviewed
Staff Information:
u  Interview Teachers and Staff as needed /

q Sent Home with Student on Date______

q Mailed to home address

Date______

q Date______

q Date______

SEE NURSES NOTES Y N
Signtures on REQUIRED forms:
* Assessment from parent
* Consent to share information
* Medication authorization
*Consent for release of medical info / ÿ RECEIVED Date:______
ÿ RECEIVED Date:______
ÿ RECEIVED Date:______
ÿ RECEIVED Date:______

Contact Health Care Provider:

u  Obtain signature for Physician Authorization Form for medication/treatments, etc. /

q Consent for release of information sent

If needed

q Authorization form signed

Student Assessment / Interview

u  Student Issues/ Needs/ Coping
u  Student actions to prevent emergencies / q Student assessment Date______

To Do Dates Completed

Staff who need to know…what to do

u  Staff in classroom(s), Staff in school office,on playground, in cafeteria,
on field trips, providing transportation / q Staff identified and given information
AFTER Consent to share information obtained

Necessary materials

u  Equipment (nebulizer, scissors, etc.)
u  Medications (Epi-Pen, etc.)
u  Materials (gloves, bandages, etc.) / q Equipment obtained
q Expiration date is______
On RX labeled______

**Emergency Care Plan written

Plan Reviewed by parent
Care Plan Sent to PCP to be Reviewed
Reviewed by Student / q Plan written
q Sent home with student Date:______
q Mailed to home Date:______
q FAX to ______
Date______
q Date______Signed back of ECP

Staff training

u  Location of plan (copies of plans)
u  Location of equipment/meds
u  Explicit steps to follow
u  Practice
Emergency Care Plan distributed to #1,2,3 trained staff listed on ECP
ECP to Coaches, Transportation staff
ECP TO TEACHERS/STAFF who have a need to know
ECP given to School District LPN or health room aide or front office staff /

q Staff trained, confident

q Date______

q Date______

q NAMES DATES

q Date______

If Emergency Occurs Staff to Complete / q 911 Emergency checklist
After emergency occurs, debrief with staff, parents students EMS, health care provider…whatever is appropriate. / Date of debrief

Completed by School Nurse(s): ______