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EL PASO COUNTY SCHOOL HEALTH SERVICESPRACTITIONER’S WRITTEN ORDER/ASTHMA ACTION PLANI. PHYSICIAN SECTIONStudent Name:DOB:ID#:Grade:School Year: 20-20School Name:Medical Diagnosis:Asthma SeverityTriggersExercise FORMCHECKBOX Intermediate FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Colds FORMCHECKBOX Smoke FORMCHECKBOX Weather FORMCHECKBOX Exercise FORMCHECKBOX Dust FORMCHECKBOX Air FORMCHECKBOX Pollution FORMCHECKBOX Animals FORMCHECKBOX Food FORMCHECKBOX OtherPhysician recommendations for Air Quality Alert Days: (Check One) FORMCHECKBOX No outdoor exercise FORMCHECKBOX Limited outdoor activity (no sprints, running, etc.) FORMCHECKBOX Exercise as toleratedGREEN ZONEPeak Flowsto(peak flow between 80-100% of personal best) FORMCHECKBOX No control medicines required OROral control medicationtakentimes a day.puff(s)HFAtimes a day.nebulizer treatment(s)times a day.For asthma with exercise:puff(s)15-20 minutes before exercise.YELLOW ZONEPeak Flowsto(peak flow between 50-80% of personal best): Tightness to chest, cough or mild wheeze, signs of upper respiratory illness, unable to exercisepuff(s)HFA everyhours as needed ORnebulizer treatment(s) every hours as needed.Comments or special Instructions:RED ZONEPeak Flows below(peak flow less than 50% of personal best): EMERGENCY ACTION IS NECESSARY WHEN THIS STUDENT HAS SYMPTOMS SUCH AS: ● Can’t talk, eat or walk well ● Medicine is not helping ● Chest/neck retractions ● Breathing hard & fast ● Blue lips and/or fingernails PO2 Less than____________%puff(s)HFA everyminutes for treatments ORnebulizer treatment everyminutes for treatments. FORMCHECKBOX Call 911Comments or special Instructions:Additional Medications:NameDosageFrequencyMedical Equipment: Please list any medical equipment this student will need to treat his/her asthma at school. (i.e., spacer, oxygen, nebulizer, etc.) FORMCHECKBOX Yes FORMCHECKBOX NoI, the signed physician, certify that the student has asthma and is capable of carrying and self-administering the above quick-relief asthma medication.Physician’s SignatureDateII. PARENT/GUARDIAN SECTION/SECCION DE PADRES/TUTOR Student Name:DOB:ID#Grade:(Nombre del Estudiante)(Fecha de Nacimiento)(# de Indentificion) (Grado)Parent/Guardian Name:________________________Phone Number:_____________Cell Number:______________(Nombre del Padre/Tutor)(# de Telefono)(Celular)Parent/Guardian Name:Phone Number:Cell Number:(Nombre del Padre/Tutor)(# de Telefono)(Celular)Emergency Contacts/Contactos de Emergencia:Name:Phone Number:Relation:(Nombre)(# de Telefono)(Relacion)Name:Phone Number:Relation:(Nombre)(# de Telefono)(Relacion) Parent/Guardian Authorization and Responsibility: I, the undersigned, parent/guardian of the above named student, request that all procedures and administration of medication be performed as authorized by the Health Care Provider for my child in accordance with state laws and regulations. I understand medication may only be administered by licensed health professionals, and trained unlicensed personnel, according to state laws and regulations. I agree to: 1. Notify the school nurse if there are any changes in my child’s medical condition and treatment plan. 2. Maintain current phone numbers with the school nurse and school office in case 911 is called. 3. Provide the necessary medication, supplies, and equipment for my child’s treatment while at school. -285751524000Yes-285751524000No I give permission for my child to carry his/her inhaler, in accordance with physician’s instructions above -36406617250800Parent/Guardian’s SignatureDateResponsabilidad de Padre/Tutor: Yo, el abajo firmante, padre o tutor del estudiante nombrado arriba, solicita que sea realizado todos los procedimientos y la administración de medicamento según lo autorizado por el proveedor de salud de mi hijo de acuerdo con las leyes y reglamentos estatales. Entiendo que el medicamento sólo puede ser administrado por profesionales de salud licenciados y personal sin licencia que ha sido entrenado conforme a las leyes y reglas estatales. Estoy de acuerdo en: 1. Notificar a la enfermera si hay algún cambio en la condición médica de mi hijo y/o el plan de tratamiento. 2. Mantener los números de teléfono actuales con la enfermera o la oficina escolar en caso de que se llama al 911.3. Proporcionar el medicamento, suministros y equipos necesarios para el tratamiento de mi hijo/a en la escuela. -37295755181500-28575-698500Si-19685-698500No Doy permiso para que mi hijo/a cargue su inhalador, de acuerdo con las instrucciones del médico delineadas arriba.Firma de Padre o TutorFecha

What is the ICD 10 code for thrombectomy with dialysis? 26608-59-LT 48. 33207 Insertion, pacemaker, heart 49. 68811-RT Nasolacrimal Duct, exploration with anesthesia 50. 12032 Wound, repair, intermediate 51. 52204 Cystourethroscopy, with biopsy. Fulguration was used for hemostasis, an integral part of the procedure. 52. 36831 Thrombectomy, Dialysis Graft, without revision