You need to know that we will administer the epi-pen if your child is experiencing ANY of the following symptoms:

Transcription

1 MEDICATION ADMINISTRATION AND FOOD ALLERGY POLICY We want to make you aware of the steps Silver Spring Day School (SSDS) is taking to assure the safety of children with serious allergies or a medical condition. Please review this document carefully, as it outlines a change in policy and steps that need to be taken by parents to comply with this new policy. It is required that this document be signed by the parent or guardian of children with medication at the school, showing compliance and understanding of the following policy: MEDICATION In order for a staff member or substitute teacher to administer the epi-pen, asthma inhaler or any other medication, the following documents need to be signed: 1. Medication Authorization Form -- signed by parent/guardian for each medication provided to SSDS; initial 2. Release and Indemnification Agreement -- signed by parent/guardian AND physician; initial 3. Food Allergy or Medication Administration Action Plan -- signed by parent/guardian AND physician. initial It is important that the epi-pen(s) and other prescription medication be provided with the doctor s prescription on the box or that a copy of the prescription be copied and kept with the prescription medication. If your child is prescribed and epi-pen, a pack of two needs to be provided in both the classroom and the office. SSDS does NOT accept Twin Jects. initial You need to know that we will administer the epi-pen if your child is experiencing ANY of the following symptoms: 1. wheezing; 2. trouble breathing; 3. trouble swallowing; 4. swelling in the face; 5. an all-over skin reaction. ADMINISTRATION OF THE EPI-PEN IS AN AUTOMATIC CALL TO 911 initial SNACKS SSDS enforces a NO-NUT policy. If your child has allergies to other foods besides nuts, a list of snacks that are safe for your child to eat needs to be provided to your child s teacher and the SSDS. Please be aware of special days during the school year when food may be provided by the school (such as after the Halloween parade and pizza/pajama days) and discuss an alternate menu with your child s teacher. initial FIELD TRIPS During field trips, it is the parent or guardian s responsibility to make sure that teachers have the child s emergency-required medication along with the Medication Authorization form and an action plan if applicable. The child must be accompanied at all times by a staff member trained in Medication Administration. If this is not possible, then the child must be accompanied by his or her parent or guardian, otherwise the child will not be able to participate in the field trip. initial CHAIN OF RESPONSIBILITY A list of responsible adults available in the classroom and/or the school office need to be identified who are familiar with the situations in which medication needs to be administered and who are informed about how to administer the medication. initial =============================================================================================== I have reviewed and understand the above medication-administration, snack and field trip policies and have discussed the special needs of my child with the teacher and a member of SSDS administrative staff. I have returned signed copies of 1. the Medical Authorization form; 2. the Release and Indemnification Agreement, and 3. the Food Allergy or Medication Administration Action Plan and/or Asthma Action Plan o a member of the SSDS staff. Parent/Guardian Teacher Administrative Staff Member - - Date - - Date - - Date SSDS-TimeCapsule: :Allergy Forms:Medication Administration Policy.doc 9/2/11

2 Medication Authorization Checklist For: name of student Medication Administration and Food Allergy Policy Medication Authorization Form Action Plan for EpiPen or asthma inhaler Release and Indemnification Two sets of epi-pens (if applicable ) and/or inhaler (if applicable) for office and classroom Picture (optional) SSDS-TimeCapsule: :Allergy Forms:Medication Authorization Checklist.doc 9/2/11

3 MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care MEDICATION ORDER FORM Regulations permit child care providers to give prescription and non-prescription medication to children in care under certain conditions. Prior written permission from the child s parent is a requirement. If possible, arrange the time of dosage so the child receives the medication at home. Fill out a separate form for each prescription or non-prescription drug. PRESCRIPTION MEDICATIONS: Prescription medications must be in a container labeled by the pharmacy or physician with the child s name and expiration date. The child may receive medication only according to the written instructions of the health practitioner or the medication label, as show below. NON-PRESCRIPTION MEDICATIONS: A child may receive only one dose per illness, except acetaminophen (Tylenol) and topical medication. A licensed health practitioner must approve the medication and dosage for the child to receive more than one dose. Name of Child: This medication is being given for the following condition(s): MEDICATION DOSAGE WHEN TO GIVE DATES TO ADMINISTER START STOP ADDITIONAL INSTRUCTIONS (including instructions not given on the prescription): Note any side effects of this medication: Note any reasons or conditions when this medication should be stopped or not given: I/We authorize to administer the above named medication to my/our child. Name of Child Care Provider or Facility Signature of Parent: Date: COMPLETE ONLY IF MORE THAN ONE DOSE OF NON-PRESCRIPTION MEDICATION IS TO BE GIVEN Instructions for more than one dose of a non-prescription medication: Note any side effects of this medication: Note any reasons or conditons when this medication should be stopped or not given: Signature of Health Practitioner: Stamp, Print or Type Name of Health Practitioner Date: Phone Number If the above section is not signed by the health practitioner, the health practitioner/designee must give oral permission to the provider directly, and the provider must complete the following: Name of Practitioner or designee giving approval: Signature of person receiving approval from health practitioner: Date: Time: OCC 1216 (Revised 7/05) Side 1 All previous editions are obsolete.

4 MEDICATION ADMINISTERED The Provider or facility shall maintain a record of the administration of medication. Keep this form in the child s permanent record while the child remains in the care of this provider or facility. Child s Name: Date to stop giving medication: Medication: DATE TIME DOSAGE REACTIONS OBSERVED (IF ANY) SIGNATURE OCC 1216 (Revised 7/05) Side 2 All previous editions are obsolete.

5 Asthma Action Plan For: Doctor: Date: Doctor s Phone Number Hospital/Emergency Department Phone Number GREEN ZONE YELLOW ZONE RED ZONE Doing Well No cough, wheeze, chest tightness, or shortness of breath during the day or night Can do usual activities And, if a peak flow meter is used, Peak flow: more than (80 percent or more of my best peak flow) My best peak flow is: Before exercise Asthma Is Getting Worse Cough, wheeze, chest tightness, or shortness of breath, or Waking at night due to asthma, or Can do some, but not all, usual activities If your symptoms (and peak flow, if used) return to GREEN ZONE after 1 hour of above treatment: Continue monitoring to be sure you stay in the green zone. -Or- If your symptoms (and peak flow, if used) do not return to GREEN ZONE after 1 hour of above treatment: Take: 2 or 4 puffs or Nebulizer (short-acting beta 2 -agonist) Add: mg per day For (3 10) days (oral steroid) Call the doctor before/ within hours after taking the oral steroid. -Or- Peak flow: to (50 to 79 percent of my best peak flow) Medical Alert! Very short of breath, or Quick-relief medicines have not helped, or Cannot do usual activities, or Symptoms are same or get worse after 24 hours in Yellow Zone -Or- Peak flow: less than (50 percent of my best peak flow) Take these long-term control medicines each day (include an anti-inflammatory). Medicine How much to take When to take it 2 or 4 puffs 5 to 60 minutes before exercise First Second Take this medicine: Add: quick-relief medicine and keep taking your GREEN ZONE medicine. (short-acting beta 2 -agonist) (short-acting beta 2 -agonist) (oral steroid) Then call your doctor NOW. Go to the hospital or call an ambulance if: You are still in the red zone after 15 minutes AND You have not reached your doctor. 2 or 4 puffs, every 20 minutes for up to 1 hour Nebulizer, once 4 or 6 puffs or Nebulizer mg DANGER SIGNS Trouble walking and talking due to shortness of breath Take 4 or 6 puffs of your quick-relief medicine AND Lips or fingernails are blue Go to the hospital or call for an ambulance NOW! (phone) See the reverse side for things you can do to avoid your asthma triggers.

6 SILVER SPRING DAY SCHOOL 801 University Blvd, West Silver Spring, MD EMERGENCY CARE FOR MANAGEMENT OF ANAPHYLAXIS Release and Indemnification Agreement for Epinephrine Injection PART 1: TO BE COMPLETED BY THE PARENT/GUARDIAN I hereby authorize Silver Spring Day School (SSDS) personnel to administer epinephrine injection as directed by the physician (Part II). I agree to release, indemnify, and hold harmless SSDS and any of their officers, staff members, or agents from lawsuit, claim, demand, or action against them for administering the injection, provided they follow the physician s order as written in Part II below. I am aware that the injection may be administered by a specifically trained non-health professional. I understand that the rescue squad will always be called when epinephrine is given, whether or not the student manifests any symptoms of anaphylaxis. Student Name / / Birthdate / / Signature, Parent/Guardian Phone Number Date PART II: TO BE COMPLETED BY THE PHYSICIAN Emergency injections are usually administered by non-health professionals, who may be either a SSDS staff member or co-oper. These persons are taught by a health professional to administer the injection. For this reason, only premeasured doses of epinephrine may be given. NOTE: These staff members are not health professionals and therefore cannot observe for the development of symptoms before giving the injection. 1. Name of medication: EpiPen (Epinephrine Auto Injector) Ana_Kit and TwinJector will not be accepted at SSDS EpiPen will not be accepted for the management of asthma. 2. Reason for medication: Management of acute allergic reactions: Check (ü ) one o Insect sting (bees, wasps, hornets, yellow jackets) o Ingestion of (specify): o Other allergen(s) (specify under what circumstances: 3. Administration into anterolateral aspect of the thigh 4. Dosage of medication: Check (ü ) one o EpiPen 0.15 mg. o EpiPen 0.3 mg. 5. Repeat dose in 15 minutes if rescue squad had not arrived.* o Yes o No *NOTE: For a repeat dose, a second EpiPen must be ordered and brought to school. 6. Side effects: Palpitations, rapid heart rate, sweating, nausea and vomiting Remarks THIS MEDICATION AUTHORIZATION IS ONLY VALID FOR THE CURRENT SCHOOL YEAR / / Physician Name Please Print or Type Phone Number Original Signature, Physician Date PART III: TO BE COMPLETED BY ADMINISTRATIVE STAFF MEMBER o Parts I and II are completed including signatures. It is acceptable if all items in Part II are written on the physician s stationery/prescription o Medication properly labeled by a pharmacist. EpiPen(s) received: o 1 dose o 2 doses Reviewed by / / Signature, School Administrator Date SSDS-TimeCapsule: :Allergy Forms:Release & Indemnification.doc 9/2/11

7 INFORMATION AND PROCEDURES 1. No medication will be administered in school or during schoolsponsored activities without the parent s/guardian s written authorization and a written physician order. This includes both prescription and over-the-counter (OTC) medications. 2. The parent/guardian is responsible for completing Part I and obtaining the physician s statement on Part II. This is required every school year for each new or continuing order or if there is a change in dosage or time of administration during the school year. (A physician may use office stationery or prescription pad in lieu of completing Part II). Information necessary includes: child s name, diagnosis, medication name, dosage, time of administrations, duration of medication, side effects, physician signature, and date. 3. The medication must be delivered to the school by the parent/guardian, or, under special circumstances an adult designated by the parent/guardian. 4. All prescription medication must be provided in a container with the pharmacist s label attached. Non-prescription OTC medication must be in the container with the manufacturer s original label. Physician samples must be appropriately labeled by the physician.

8 Food Allergy Action Plan Student s Name: D.O.B. Teacher: ALLERGY TO: Asthmatic: Yes*o No o *Higher risk for severe reaction u STEP 1: TREATMENT u Symptoms: Give Checked Medication**: **(To be determined by physician authorizing treatment) n If a food allergen has been ingested, but no symptoms: o Epinephrine o Antihistamine n Mouth Itching, tingling, or swelling of lips tongue, mouth: o Epinephrine o Antihistamine n Skin Hives, itchy rash, swelling of the face or extremities: o Epinephrine o Antihistamine n Gut Nausea, abdominal cramps, vomiting, diarrhea: o Epinephrine o Antihistamine n Throat Tightening of throat, hoarseness, hacking cough: o Epinephrine o Antihistamine n Lung Shortness of breath, repetitive coughing, wheezing: o Epinephrine o Antihistamine n Heart Weak or thready pulse, low blood pressure, fainting, pale, blueness: o Epinephrine o Antihistamine n Other o Epinephrine o Antihistamine n If reaction is progressing (several of the above areas affected), give: o Epinephrine o Antihistamine Potentially life-threatening. The severity of symptoms can quickly change. DOSAGE Epinephrine: inject intramuscularly (circle one) EpiPen EpiPen Jr (see reverse side for instructions) SSDS does not accept Twinjects Antihistamine: give Other: give IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine in anaphylaxis. CHAIN OF RESPONSIBILITY Below is a list of responsible adults available in the classroom and/or the school office who have been identified as familiar with the situations in which medication needs to be administered and who are informed about how to administer the medication u STEP 2: EMERGENCY CALLS u 1. Call 911. State that an allergic reaction has been treated, and additional epinephrine may be needed. 2. Dr. Phone Number: 3. Parent Phone Number(s) 4. Emergency Contacts: Phone Number(s) Name/Relationship a. 1.) 2.) b. 1.) 2.) EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY! Parent/Guardian s Signature Doctor s Signature (Required) Date Date SSDS-TimeCapsule: :Medical Condtion/Allergy:Food Allergy Action Plan.doc 9/2/11