Primary Care Provider (Pcp) Authorization Form: Respiratory Disorders - Jefferson County Public Schools Health Services
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2Jefferson County Public Schools Health Services
Primary Care Provider (PCP) Authorization: Respiratory Disorders (Side One)
2012-2013 School Year
Student Name: _________________________ Date of Birth: ____________ School: ______________________________
***DIAGNOSIS:___________________________________
***LATEX ALLERGY
YES
NO
OXYGEN SUPPLEMENTATION
TRACHEOSTOMY SUCTIONING/REPLACEMENT
Oxygen Vendor/Phone Number: ____________________________
Type and size of trachea tube: ______________________________
Specific Instructions for use of Portable Oxygen:
Suctioning Frequency (Check one and fill in):
Liters per minute: _______ via:
Every _______ minutes
Every _________hours
Nasal cannula
Mask
Tracheostomy collar
As needed based upon signs and symptoms as follows:
Choking
Continuous coughing
Gurgling
Times for use:
Upon student’s request
Other (Specify): __________
Continuous
While Sleeping/Naps
Sats. ___________________
Respiratory Distress
Other____________________________
Suctioning Instructions: (Parents need to supply saline and catheters)
PULSE OXIMETER
Saline installation needed
Depth to insert catheter: _________
Use of pulse oximeter is only encouraged if the child routinely receives
Other (Explain): ________________________________________
VENTILATOR
oxygen saturation monitoring at home.
Student’s NORMAL BASELINE oxygen saturation is ______%
Equipment Company/Phone Number: ___________________________________
Type of Ventilator: ___________________________________________________
Please indicate when student should have oxygen saturation checked
Ventilator Settings: ___________________________________________________
with a pulse oximeter (Check all that apply. If PRN provide SPECIFIC
____________________________________________________________________
guidelines):
Before every breathing treatment
After every breathing treatment.
Does student need ventilator at school?
YES
NO
When signs of respiratory distress (specify symptoms):______________
_____________________________________________________________
Student Needs Ventilator:
Continuously
During Nap/Sleep Only
Other (specify):_____________________________________________
Other: ____________________________________________________
___________________________________________________________
Specific Instructions for Ventilator (i.e. signs & symptoms to look for when
Recommended Interventions (Check ALL that apply):
taking naps/sleeping , etc.): ____________________________________________
____________________________________________________________________
Encourage student to assume position of comfort
Administer Nebulizer treatment/Inhaler (see Asthma PCP form)
Additional Health Care Provider’s Comments: _____________________
Encourage slow, deep, even breaths
______________________________________________________________
If Sats are below _____% Initiate Oxygen at ________ Liters/Minute
______________________________________________________________
If Sats are between _____% & ______% call parent
If Sats are below ______% CALL EMS (9-911)
Please complete both sides of this form. Form must be signed by Health Care Provider and Parent/Guardian
Initials/Date
Reviewed by Health Services
___________
Entered by Health Services
___________
School received/sent to Health Services ___________
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