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Nursing and School Health Services Treatment Form

Student’s Last Name: MI: First Name: DOB: Date: _________

Student ID: Gender: School: District: Manteca Unified School District
Health Condition: IEP IHP 504 Date of Most Recent Nursing Plan: ___________
Instructions: Document actual clock time spent with individual student performing MD-prescribed service(s) in nursing plan. See most recent Nursing Plan for treatment plan, medications, protocols, and emergency contacts. Treatment services are billed to
Medi-Cal in 15-minute increments. One unit of service may be billed if a minimum of 7 or more continuous minutes of direct service time is provided to a student. A unit cannot be made-up of shorter time periods provided throughout the day and added
together. The “units” column below refers to the number of billable units of service.

Trach Suctioning Procedures / Interventions

# of Mins. Secretions Observations / Concerns
= Units Y =yellow Codes: Codes:
0-6 = 0 G = green Tolerated Irrigated A = Alert, Attentive/involved CEA = Clean equipment after suction
7-15 = 1 HTT = Head to toe assessment-see nursing E = Education
15-22 = 1 notes PC = Parent present
22-30 = 2 C = Coughing PR = Parent response in person
30-37 = 2 O2 L = Lung sounds – see nursing notes

Drain- SQN = See Q notes




37-45 = 3 age SA = O2 sats
45-52 = 3 SK = Skin color pail or blue
Time Time Total 52-60 = 4 T = Tired/Sleepy TP = Tolerated poorly
Date In Out Min 60-67 = 4 IS = Insufficient supplies Initials

*Attach separate Progress Notes page if more space is needed to describe any changes, events, or concerns.
By signing below, I certify that I have been trained by the school nurse to observe, monitor, and provide health- By signing below, I certify that the person to the left was trained to observe, monitor, and provide health-related
related interventions for this student. interventions for this student.
Printed Name Auth. Title Signature Initials Date Printed Name Auth. Title Signature Initials Date
RN, LVN Credentialed
School Nurse