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Run: Student Individual Healthcare Plan (IHP)

This Student Individual Healthcare Plan (IHP) template documents a student’s condition, daily care needs, emergency steps, and staff delegation instructions....

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Plan Identification

Student full name (required)

Student ID

Date of birth

Grade level

School name (required)

Plan effective date (required)

Planned review date

Primary health condition (required)

Briefly describe the chronic condition or health need this plan addresses.

Health Status and Care Needs

Condition summary (required)

Describe the condition in school-appropriate terms, including how it may affect attendance, learning, mobility, nutrition, or participation.

Common symptoms or warning signs (required)

List observable symptoms staff should recognize.

Known triggers or aggravating factors

Activity limitations

Describe any restrictions or accommodations for PE, recess, field trips, or transportation.

Nutrition or hydration needs

Include meal timing, snacks, water access, or feeding support if applicable.

Required healthcare equipment or supplies

Routine Nursing Interventions

Is daily monitoring required? (required)

Monitoring details

Describe what should be monitored, how often, and what values or observations should be documented.

Routine nursing interventions (required)

List the interventions to be performed during the school day, including timing and any required supplies.

Medication or treatment provided at school (required)

Medication or treatment details

Include the treatment name, schedule, route, and any school handling instructions. Do not collect unnecessary PII.

Special accommodations

Emergency Response Plan

Emergency signs or red flags (required)

Describe the symptoms or situations that require immediate action.

Immediate actions for staff (required)

Provide step-by-step actions to take before the nurse arrives or emergency services are contacted.

When to call parent or guardian (required)

State the situations that require family notification and the preferred contact order.

When to call emergency services (required)

List the criteria for calling 911 or local emergency services.

Emergency contact instructions

Include any school-specific escalation or after-hours instructions.

Delegation and School Staff Instructions

Is delegation required? (required)

Delegated tasks

Authorized staff roles

Identify the staff roles or positions authorized to carry out delegated tasks after training and competency validation.

Training and competency validation

Document training topics, competency checks, and any refresh schedule required for safe delegation.

Supervision requirements

Describe when the nurse must be present, available by phone, or provide direct supervision.

Substitute coverage plan

Explain what happens if the assigned staff member is absent or unavailable.

Consent, Communication, and Review

Parent or guardian consent to share relevant health information with school staff (required)

Consent is limited to the minimum necessary information needed to support the student during the school day.

Yes No N/A

Communication preferences

List preferred contact methods and any language or accessibility needs.

Additional notes

Use this field only for information directly related to the healthcare plan.

Plan review frequency (required)

Reviewer name

Review date

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