Nutrition And Feeding Care Plan Page 2
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1
2Behavior Changes
(be specific when listing changes in behavior that arise before, during, or after feeding/eating)
Medical Information
Information Exchange Form completed by Health Care Provider is in child’s file onsite.
❏
v Medication to be administered as part of feeding routine:
❏ Yes
❏ No
Medication Administration Form completed by health care provider and parents is in child’s file on-site
❏
(including type of
medication, who administers, when administered, potential side effects, etc.)
Tube Feeding Information
Primary person responsible for daily feeding:
Additional person to support feeding:
❏ Breast Milk
❏ Formula
(list brand information):
Time(s) of day:
Volume
____________________ Rate of flow: ____________________ Length of feeding:
(how much to feed):
Position of child:
❏ Oral feeding and/or stimulation
(attach detailed instructions as necessary):
Special Training Needed by Staff
Training monitored by: _________________________________________
1) Type
(be specific):
Training done by: _____________________________________________
Date of Training:
2) Type
(be specific):
Training done by: _____________________________________________
Date of Training:
Additional Information
(include any unusual episodes that might arise while in care and how the situation should be handled)
Emergency Procedures
❏ Special emergency and/or medical procedure required
(additional documentation attached)
Emergency instructions:
Emergency contact: _______________________________________________ Telephone:
Follow-up: Updates/Revisions
This Nutrition and Feeding Care Plan is to be updated/revised whenever child’s health status changes or at least every ___ months as
a result of the collective input from team members.
Due date for revision and team meeting: ______________
Page 2 of 2
California Childcare Health Program rev. 05/03
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