Individual Health Plan (IHP)

Instructions to Complete an Individual Health Care Plan (IHP) 


Section I: Identifying Information — Provide detailed information

  1. Student’s Information
  2. Parents/Guardians Information
  3. Physician’s Information
  4. Hospital Information
  5. School Nurse Information


Section II. Medical Overview — Complete the questions on the lines provided

  1. Medical Condition: include ALL medical conditions (i.e., food allergies, asthma)
  2. Medications: include ALL medications
  3. Side Effects: include ANY side effects from medications
  4. Necessary Health Care Procedures at School
  5. Healthcare Plan for Period: include start and end date


Section III. Other Information — add in optional information that has not been covered in the IHP


Section IV. Background Information/Nursing Assessment — provide detailed information on the following, if necessary check the box and attach additional sheets.

  1. Medical History: description of the child’s past allergic reactions, include triggers, signs/symptoms, and the child’s verbal description
  2. Social/Emotional Concerns: describe how the medical conditions can cause social and emotional response in the child and require the need for support
  3. Academic Achievement: describe academic achievements and/or challenges that can be affected due to the medical condition(s)


Section V. Interventions — Provide detailed information on the following, if necessary check the box and attach additional sheets.

  1. Medications: List medications or refer to Emergency Care Plan (ECP)  and/or Food Allergy Action Plan  (FAAP)
  2. Diet: List meal substitutions; note if parent/guardian is requesting the school provide school meal substitutions then a written physician statement is necessary
  3. Transportation: List the student’s form of transportation to/from school: bus, car, walker; Note: it is highly recommended that no eating/drinking is allowed on the bus
  4. Classroom School Modifications: Consider seating assignments; handwashing schedules/procedures; cleaning procedures for chairs/desks
  5. Equipment: Remember emergency medications, first aid kit, cleaning supplies, snacks
  6. Safety Measures: Attach Emergency Care Plan (ECP), Food Allergy Action Plan (FAAP), 504 Plan/IEP
  7. Substitute Backup Staff: It is highly recommended that all substitute staff be included in training
  8. Possible Problems: i.e., all staff training; staff/parent/guardian resistance with procedures; understanding that food allergies are life-threatening
  9. Training: Consider annually/biannually; do the parents/guardians want to participate


Section VI. Individual Health Plan Review — Document Next Review Date 


Section VII. Documentation of Participation — Have ALL school staff members who are identified as responsible parties read, review and sign the IHP.


Section VIII. Parent/Guardian Authorization for Special Health Services — provide child name, DOB, and parents/guardians signature/date.


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