CHOC Seizure Action Plan

SEIZURE ACTION PLAN
Parent Consent and Healthcare Provider Authorization
For Management of Seizures at Home, School and School Sponsored Events
THIS CHILD IS BEING TREATED FOR A SEIZURE DISORDER.
THE INFORMATION BELOW SHOULD ASSIST YOU IF A SEIZURE OCCURS.
Please bring this form with you should your child need to be seen in the Emergency Department.
Parent/Guardian:________________________ Phone: ______________ Cell:________________
Treating Neurologist: ____________________ Phone: ______________ FAX: ______________
School Name: __________________________ Phone: ______________ FAX: ______________
Significant medical history:__________________________________________________________
Allergies:________________________________________________________________________
SEIZURE INFORMATION:
Seizure Type Length Frequency Description
Seizure triggers or warning signs: ____________________________________________________
Childʼs reaction to seizure: __________________________________________________________
DAILY SEIZURE MEDICATIONS:
Medication Dosage Directions Side Effects
BASIC FIRST AID: CARE & COMFORT:
(Please describe basic first aid procedures
Basic Seizure First Aid:
✓ Stay calm & track time
✓ Keep child safe
✓ Do not restrain
✓ Do not put anything in mouth
✓ Stay with child until fully
conscious
✓ Record seizure in log
For tonic-clonic
(grand mal) seizure:
✓ Protect head
✓ Keep airway
open/watch breathing
✓ Turn child on side
A Seizure is generally considered an
Emergency when:
✓ A convulsive (tonic-clonic) seizure lasts
longer than 5 minutes
✓ Child has repeated seizures without
regaining consciousness
✓ Child has a first time seizure
✓ Child is injured or has diabetes
✓ Child has breathing difficulties
✓ Child has a seizure in water
455 South Main St.
Orange, CA 92868
PATIENT I.D.
SEIZURE ACTION PLAN
99280 (9/08) Page 1 of 3

SEIZURE ACTION PLAN
Parent Consent and Healthcare Provider Authorization
For Management of Seizures at Home, School and School Sponsored Events
EMERGENCY RESPONSE:
A “seizure emergency” for this child is defined as:________________________________________
______________________________________________________________________________
______________________________________________________________________________
Seizure Emergency Protocol: (Check all that apply and clarify below)
Contact school Nurse
Call 911 for transport to __________________________________________________________
Notify parent or emergency contact
Parent to notify doctor
(CHOC Neurology Clinic at 714-532-7601 (M-F 8-4:30) or 866-316-3347 (after hours)
Administer emergency medications as indicated below
Other ________________________________________________________________________
“AS NEEDED” TREATMENT PROTOCOL:
Emergency/Rescue Medication
Diastat _________ mg Acudial:
• Give ______mg per rectum for seizures > ____minutes; or in clusters > ____seizures in 1 hr
• Call 911 if the seizures do not stop ______ minutes after you give the rescue medication or if
child has problems breathing during or after the seizure.
• Side Effects: drowsiness, sleepiness, fatigue, poor coordination, unsteadiness, behavior
change
Does child have a Vagus Nerve Stimulator (VNS)? YES NO
If YES, Describe magnet use ________________________________________________________
Parental Instructions for Routine Medication Dose Change
Medication Dosage & Directions When to Give
455 South Main St.
Orange, CA 92868
PATIENT I.D.
SEIZURE ACTION PLAN
99280 (9/08) Page 2 of 3

SEIZURE ACTION PLAN
Parent Consent and Healthcare Provider Authorization
For Management of Seizures at Home, School and School Sponsored Events
SPECIAL CONSIDERATIONS & SAFETY PRECAUTIONS:
(re: school activities, sports, trips, etc.)
None
No contact sports
No use of power tools/power equipment
No swimming
Other: ________________________________________________________________________
Does child need to leave the classroom after a seizure? YES NO
If YES, describe process for returning child to classroom __________________________________
______________________________________________________________________________
Authorized Health Care Provider Authorization for Management of Seizures at School
My signature below provides authorization for the above written order, including administration of
Diastat. I understand that all procedures will be implemented in accordance with state laws and
regulations. I understand that specialized physical health care services may be performed by
unlicensed designated school personnel under the training and supervision provided by the school
nurse. This authorization is for a maximum of one year. If changes are indicated, I will provide new
written authorization (may be faxed).
CHOC Neurology Department:
Neurologist Signature __________________________ Date: __________Time: __________
1120 West LaVeta Ave. #125, Orange, CA 92868 Phone # (714) 532-7601 Fax # (714) 532-7650
Parent Consent for Management of Seizures at School
I (We), the parent/guardian of the above named student request that the following for Management of
Seizures in school be administered to our child in accordance with state laws and regulations.
I will:
1. Provide the necessary supplies and equipment, including 3 day emergency supply of
medication
2. Notify the school nurse if there is a change in the student health status or change of
physician
3. Notify the school nurse immediately and provide new consent for any changes in
doctorʼs orders
I authorize the school nurse to communicate with the Authorized Health Care Provider when
necessary. I understand that I will be provided a copy of my childʼs completed Individual School
Healthcare Plan (ISHP)
Parent Signature: ____________________________________________ Date: ________________
School Nurse Signature: ______________________________________ Date: ________________
455 South Main St.
Orange, CA 92868
PATIENT I.D.
SEIZURE ACTION PLAN
99280 (9/08) Page 3 of 3