Health Care Plan

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					                        Bucks County Intermediate Unit # 22
                                 Health Care Plan
                            (Insert Medical Diagnosis)


General Information-
Student Name__________________________Date of Birth________________________
ALLERGIES____________________________________________________________
Parents Names_______________________ Parents Home Phone___________________
Parents Work Phone_____________________ Cell Phone________________________
Physician Name & #______________________________________________________

Date of Report_____________
Problem
(Nursing diagnosis: example- Potential for injury related to tonic-clonic seizure activity)


Intervention
(Nursing actions: example- Prevention of injury; Ease student to the floor, position
student on his/her side to facilitate drainage of saliva and reduce potential for aspiration)



Protocol
(Specific to medical diagnosis)



Individualized Treatment Plan
(Specific to individual student needs)




Form Completed by______________________________
Date_______________




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