Form H.4.6 - Student Health Referral
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1STUDENT HEALTH REFERRAL
AUGUST 2001
H.4.6
STUDENT HEALTH REFERRAL
Name: ___________________________________ Date:___________ Time Sent: _______
Referring Adult:____________________________________________________
Complaint: Specified by student, teacher or parent
____ Asthma
____ Headache
____ Sore throat
____ Burn
____ Head Injury
____ Joint Injury
____ Cut/Laceration
____ Insect Bite
____ Possible Fracture ____ Earache
____ Stomach Discomfort
____ Eye Problem
____ Seizure
____ Cold Symptoms
____ Possible Fever
____ Skin Problem
____ Vomiting/Diarrhea ____ Personal
____ Other: _______________________________
Comments: _____________________________________________________________
Observations: _____________________________________________________________________
Vital Signs @
______
Temp _______ BP _______ Pulse _______ Resp _______ LOC _______ PERRLAEOM _______
as needed:
@ _______
Temp _______ BP _______ Pulse _______ Resp _______ LOC _______ PERRLAEOM ______
Nursing Diagnosis (NANDA): __________________________________________________________
Plan: ___________________________________________________________________
Intervention (NIC):
___ Rested ___ Elevation ___ Wound Care ___ Injury immobilized ___ Cold Application ___ Observed ____ Other
Health Counseling: ________________________________________________________
Evaluation (NOC): _________________________________________________________
Resolution:
_____ Return to class @ _______________
_____ Return to class for belongings. Send back to Nurse’s Office.
_____ Remain in Nurse’s Office
_____ Referral to Physician
Parents Notified: ___ No ___ Yes Telephone @ ______ Message left with_____________________
___Note sent home
Please:
[ ] Observe for______________________________________________
[ ] Have your child evaluated by a licensed health care provider. (Form attached)
[ ] Read attached health information.
Re-admittance criteria:
a. Fever free for 24 hours after school exclusion for temperature 100F or greater
b. No significant nausea, vomiting, or diarrhea for 24 hours
c. Chicken pox (Varicella) lesions crusted and dry, at least 5-7 days from onset
d. Lice treatment initiated
e. Impetigo lesions covered and under care of medical provider
f. Conjunctivitis, signs of infection have cleared
g. Ringworm covered, under care of medical provider
h. Scabies, 8 hours after first prescribed treatment
“Insert name and title”
1) Retain original in nurse’s office
2) Copy for Parent/Physician 3) Copy for Teacher
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Parent category: Medical