Instructions to Complete an Individual Health Care Plan (IHP)
Section I: Identifying Information — Provide detailed information
- Student’s Information
- Parents/Guardians Information
- Physician’s Information
- Hospital Information
- School Nurse Information
Section II. Medical Overview — Complete the questions on the lines provided
- Medical Condition: include ALL medical conditions (i.e., food allergies, asthma)
- Medications: include ALL medications
- Side Effects: include ANY side effects from medications
- Necessary Health Care Procedures at School
- 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.
- Medical History: description of the child’s past allergic reactions, include triggers, signs/symptoms, and the child’s verbal description
- Social/Emotional Concerns: describe how the medical conditions can cause social and emotional response in the child and require the need for support
- 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.
- Medications: List medications or refer to Emergency Care Plan (ECP) and/or Food Allergy Action Plan (FAAP)
- Diet: List meal substitutions; note if parent/guardian is requesting the school provide school meal substitutions then a written physician statement is necessary
- 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
- Classroom School Modifications: Consider seating assignments; handwashing schedules/procedures; cleaning procedures for chairs/desks
- Equipment: Remember emergency medications, first aid kit, cleaning supplies, snacks
- Safety Measures: Attach Emergency Care Plan (ECP), Food Allergy Action Plan (FAAP), 504 Plan/IEP
- Substitute Backup Staff: It is highly recommended that all substitute staff be included in training
- Possible Problems: i.e., all staff training; staff/parent/guardian resistance with procedures; understanding that food allergies are life-threatening
- 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.