Individualized Health Plan - Louisiana Department Of Education
ADVERTISEMENT
1
2CONFIDENTIAL
INDIVIDUALIZED HEALTHCARE PLAN
IHP
Louisiana Department of Education
Student’s Name_____________________________ Date of Birth __________________ ❑ Special Education
❑ General Education
School ______________________________________________ Grade ________
BACKGROUND INFORMATION/NURSING ASSESSMENT
(Complete all applicable sections.)
Brief Medical History/Specific Health Care
(Additional information is attached.)
Psychosocial Concerns ❑ Yes ❑ No
Family Concerns/Strengths ❑ Yes ❑ No
(Additional information is attached.)
(Additional information is attached.)
GOALS AND ACTIONS Individualized Healthcare Plan (IHP). Attach nursing diagnoses, interventions and evaluation, etc.
Attach physician's order and other standards for care.
1) Procedures and Interventions (student specific)
Procedure
Administered By
Equipment
Maintained
Authorized/Trained By
By
(a)
(b)
(c)
2) Medications: ❑ No ❑ Yes (If yes, attach medication
3) Diet: ❑ No ❑ Yes (If yes, attach description.)
guideline and administration log.
4) Special Transportation Needs: ❑ No ❑ Yes
5) Class/School Modifications: ❑ No ❑ Yes
Additional information is attached.
(If yes, attach additional information.)
6) Equipment and Supplies: ❑ Parent ❑ LEA ❑ None
7) Safety Measures: ❑ No ❑ Yes (If yes, attach description.)
8) Student Participation in Procedures ❑ No ❑ (If yes, attach description.)
.
CONTINGENCIES
POSSIBLE ALERTS
Emergency Plan attached
Training Plan attached
AUTHORIZATIONS I have participated in the development of the Health Services Plan and agree with the contents. Please sign and
date.
Parent//Legal Guardian _______________________
/ /
Teacher(s)________________________________
/
/
School Nurse _______________________________
/ /
Other ___________________________________
/
/
School Administrator ________________________
/
/
Other__________________________________
/
/
Effective Beginning Date
Next Review Date______________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal