Diastat Md Order Form - School Health Services printable pdf download

Mecklenburg County Health Dept

SCHOOL HEALTH SERVICES

A Partnership for Serving Children

Order: Diastat in School

Student’s Name: ___________________________________

DOB: _____________________

Student’s Address: ______________________________________________________________

Student’s Phone #: _________________________ Student’s I.D: ________________________

Mother’s Name: __________________ Phone: Work _______________Cell _______________

Father’s Name: ___________________ Phone: Work _______________Cell _______________

Preferred Hospital: ______________________________________________________________

School: ______________________________ Teacher/Grade/Homeroom: __________________

Student’s Diagnosis: ___________________________________________________________

Please have the student’s Health Care Provider complete the following information:

1. Observe seizure activity and time the seizure.

2. If seizure is longer than

minutes in duration give Diastat

mg. rectally as ordered

_____

following proper procedure.

3. Monitor vital signs.

4. Assess student for specific behaviors and movements during the seizure and complete the

seizure flow sheet. Remain with the student.

5. Notify parent/guardian. Student must be picked up from school.

6. Observe for decreased breathing or heart rate, change in color, head injury at time of seizure,

duration and number of seizures.

7. Call 911 if :

8. Document medication given on medication record.

9. Other:

Duration of order: School Year________________

Health Care Provider _______________________ Phone # _______________FAX #______________

Address:_____________________________________________________________________________

Health Care Provider’s Signature : ______________________________________

Date: _______________

(Please sign here to authorize this order and return to the School Health Program, MCHD, Hal

Marshal Annex, 618 North College Street, Charlotte, N.C. 28202 Fax: 704-432-2079 Attn:

School Health.)

I have reviewed this order and give my permission for the School Health Nurse to train school personnel

to follow this order.

Parent /Guardian Signature________________________________________Date______________

I have provided training and instruction regarding this order to: _________________________________

(Signatures of personnel trained)

_____________________________________,________________________________________

___________________________________________________

School Health Nurse Signature _____________________________________ Date______________

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Diastat Md Order Form - School Health Services

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