Get Prescriber Parent Authorization Gastro Procedure Form - Alsde

Filling out the Prescriber Parent Authorization Gastro Procedure Form is essential for ensuring proper care for students requiring gastrostomy tube assistance. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form successfully.

1. Click 'Get Form' button to access the document and open it in your preferred editor.
2. Begin with the student information section. Fill in the student's name, date of birth, school, grade, teacher's name, and the school year. Ensure all details are accurate.
3. Next, indicate any known drug allergies or reactions by checking 'Yes' or 'No.' If applicable, provide the specific allergies.
4. The prescriber authorization section must be completed by a licensed healthcare provider. Input the start and stop dates for the procedure, then detail the formula type, reason for taking, route, amount per feeding, and frequency.
5. Complete the residual and flush section by specifying whether to check the residual before feeding, notify the prescriber if residual exceeds a certain amount, and detail flush requirements before and after formula and medication administration.
6. In the storage section, specify whether the formula requires refrigeration after opening and whether the syringes or tubing should be stored in refrigeration. Also, indicate if self-care is permitted and provide recommendations if applicable.
7. Fill in the type tube details, including type (e.g., Mic-Key Button), lumen size, length, and balloon size. Confirm if the student's stoma is mature and include the date of maturity.
8. Outline treatment orders for site care or dressing changes as necessary, adding additional sheets if you require more space.
9. The licensed healthcare provider must print their name, sign, and date the form, providing their contact phone and fax numbers.
10. For parent authorization, the parent must sign, date, and provide their phone and cell numbers acknowledging the nurse's authority to communicate with prescribers.
11. If applicable, another section for self-care authorization must be completed by the parent, including an affirmation of self-care instruction and a signature.
12. Once all sections are complete, review the information for accuracy, then save changes. You can download or print the completed form for submission.

Complete your documentation online to ensure your student receives the necessary care.