School Health Workgroup

Asthma Medical Request Referral Instructions F10

Purpose:

 To communicate about the student’s asthma status/management between the Health Care Provider (HCP) and the Licensed School Nurse (LSN).

Process:

 The LSN will complete the Asthma Medical Request form (AMR) and/or contact the HCP when she/he has a student with asthma control or management concerns.

 The AMR should be sent to the HCP only after parent/guardian consent is obtained, except in the event of an emergency.

 When a student is transported by ambulance to the ED, send the Asthma Medical Request form along with the student. Fax copy to HCP (if known).

 When the student needs immediate care (based on the MPS Pathway for Asthma Care) and he/she is going to their primary clinic or urgent care, the Licensed School Nurse (LSN) should call the HCP to inform them of the referral. Send the Asthma Medical Request with the student and fax to the HCP.

 For situations not requiring immediate attention, fax the Asthma Medical Request to the clinic without calling the clinic staff to inform them of the incoming fax. Call the parent/guardian or send the Asthma Visit Notification form home informing parent/guardian that an Asthma Medical Request was faxed to clinic.

Instructions:

 The LSN will send the Asthma Medical Request when: . Student is seen in the Health Office 2 or more times a week with asthma symptoms. . Medication/peak flow meter/spacer are needed at school. . There are questions about medications. . Student experiences an acute asthma episode requiring immediate care. . Student has missed 5 or more days of school due to asthma within the current school year.

 The HCP will respond to the AMR when: . The HCP evaluated the student and there are changes in the student’s medications at home or at school. . There are school activity restrictions related to the student’s asthma status. . There are changes in the student’s AAP or new AAP has been developed. . Referrals have been made by HCP for home care, environmental assessment, case management or specialists. . HCP wants follow-up education emphasized in the School Health Office. . There are any other recommendations for school staff.

Documentation:

 Document that “Asthma Medical Request” was sent to HCP in the Pupil Health Record narrative notes.

 Document on the Daily Log that the “Asthma Medical Request” was sent to the clinic or HCP.

 File original/copy in the Pupil Health Record.

Provided courtesy of the Healthy Learners Asthma Initiative / Minneapolis Public Schools, Health Related Services www.healthylearners.org or 612-668-0850