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									                                               Asthma Medical Request Referral Instructions                                                                       F10


 To communicat e about the student’s asthma status/management between the Health Care Provider (HCP ) and the
  Licensed School Nurse (LSN).


 The LS N will complete the Asthma Medical Request form (AMR) and/or contact the HCP when she/he has a student
  with asthma cont rol or management concerns.

 The AMR should be sent to the HCP only after parent/guardian consent is obtained, except in the event of
    an emergency.

 When a student is transport ed by ambulance to the ED, send the Asthma Medical Request form along with the student.
  Fax copy to HCP (if known).

 When the student needs immediate care (bas ed on the MPS Pathway for Asthma Care) and he/she is going to their
  primary clinic or urgent care, the Licensed School Nurse (LS N) should call the HCP to inform them of the referral. Send
  the Asthma Medical Request with the student and fax to the HCP.

 For situations not requiring immediate attention, fax the Asthma Medical Request to the clinic without calling the clinic
  staff to inform them of the incoming fax. Call the parent/guardian or send the Asthma Visit Notification form home
  informing parent/guardian that an Asthma Medical Request was faxed to clinic.


 The LS N will send the Asthma Medical Request when:
   Student is seen in the Healt h Office 2 or more times a week with asthma symptoms.
   Medication/peak flow meter/spacer are needed at school.
   There are questions about medications.
   Student experiences an acut e asthma episode requiring immediate care.
   Student has missed 5 or more days of school due to asthma within the current school year.

 The HCP will respond to the AMR when:
   The HCP evaluated the student and there are changes in the student’s medications at home or at school.
   There are school activity restrictions related to the student’s asthma status.
   There are changes in the student’s AAP or new AAP has been developed.
   Referrals have been made by HCP for home care, environmental assessment, case management or specialists.
   HCP wants follow-up education emphasized in the School Health Office.
   There are any other recommendations for school staff.


 Document that “Asthma Medical Request” was sent to HCP in the Pupil Health Rec ord
  narrative not es.

 Document on the Daily Log that the “Asthma Medical Request” was sent to the clinic or HCP.

 File original/copy in the Pupil Health Record.

Provi ded courtes y of the Healthy Learners Asthma Initiati ve / Minneapolis Public Sc hools, Health R elated Ser vices www.healthylearners.org or 612-668-0850

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