Asthma Case Management Form

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Asthma-Friendly Schools Initiative Toolkit
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Asthma Case Management Form
School District: _______________________________________________________________________
ANNUAL INTENSIVE CASE MANAGEMENT SUMMARY FOR NURSES/CASE MANAGERS
ID# ______ School Year: ______ School: ____________________ Race (circle): Asian
Black
Hispanic White
Other
Name: Last________________________ First: _____________________________ MI: ______ Grade: _______
Male
Female
Date of Birth _____/_____/_____ Care Provider________________________________
Allergist/Pulmonologist: ____________________________ Date of Asthma Action Plan: _______________
None
INTERVENTION DONE
SEVERITY
THROUGH SCHOOL
Severity established by:
Doctor
School Nurse
Not established
Severity is:
Mild Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
Permission to interact with Dr.?
Exercise Induced?
Yes
No
Allergy Testing done:
Yes
No
No
Yes Date __________
Known Allergies/Sensitivities: ____________________________________________________
Sent letter/called doctor?
___/___/___
No
Yes Date __________
Assessment
CURRENT TREATMENT
Teach inhaler/spacer technique?
Date
Control Med at home or school (e.g., inhaled steroid, leukotriene modi er, cromolyn)
No
Yes
Yes
No
Teach peak ow technique?
Quick relief Rx (e.g., Albuterol)
At School
At Home
None
No
Yes
Self-carry
At School
At Home
None
Peak Flow
At School
At Home
None
Parent counseling 1:1?
Spacer
At School
At Home
None
Nebulizer
At School
At Home
None
No
Yes
Flu/Pneumo Vaccine
At School
At Home
None
Don't know
Receiving Allergy Shots
At School
At Home
Do Not Know
Student health counseling 1:1?
No
Yes
Enrolled in a special asthma program through health insurance?
At School
At Home
Do Not Know
Peak ow logs?
No
Yes
Asthma education for classmates?
SEVERITY
No
Yes
Severity established by:
Doctor
School Nurse
Not established
Severity is:
Mild Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
Open Airways for Schools received?
No
Yes Date __________
Exercise Induced?
Yes
No
Allergy Testing done:
Yes
No
Known Allergies/Sensitivities: ____________________________________________________
Parent or student support group?
___/___/___
No
Yes
Assessment
CURRENT TREATMENT
Emergency protocol on le?
Date
Control Med at home or school (e.g., inhaled steroid, leukotriene modi er, cromolyn)
No
Yes
Yes
No
Emergency protocol shared with staff?
Quick relief Rx (e.g., Albuterol)
At School
At Home
None
No
Yes
Self-carry
At School
At Home
None
Peak Flow
At School
At Home
None
P.E. teacher education?
Spacer
At School
At Home
None
Nebulizer
At School
At Home
None
No
Yes
Flu/Pneumo Vaccine
At School
At Home
None
Don't know
Receiving Allergy Shots
Staff education/counseling?
At School
At Home
Do Not Know
No (# of staff ______)
Yes
Enrolled in a special asthma program through health insurance?
At School
At Home
Do Not Know
Trigger identi cation at school?
No
Yes
Trigger modi cation at school?
Asthma Related School Events (summary of all per school year)
No
Yes
•
See worksheet on other side
Trigger identi cation at home?
•
Date this form completed ____________________________
No
Yes
Trigger modi cation at home?
Visits to health room for preventive/education: _____________________
No
Yes
ED visits for asthma (if known): ___________________________________
Home visit relating to asthma?
Visits to health room for asthma symptoms: ______________________
No
Yes Date __________
911 calls for asthma: _________________________________________
Referral to asthma camp?
Days sent home due to asthma: _________________________________
No
Yes
Hospitalizations for asthma (if known): ____________________________
Receiving allergy shots?
Total days absent: ______________________________________________
No
Yes
Do not know
Days absent known to be due to asthma: ___________________________
Enrolled in special asthma program
through health insurance?
No
Yes
Do not know
School Nurse: ________________________________________________

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