ࡱ> a bjbjڥڥ 7pR\R\ 2228j<D2!{!}!}!}!}!}!}!$#P&!!!^{!{!`_8C}Ijg!!0!&&J&/8!!0!& > : Suctioning Tracheostomy Documentation Record (page 1 of 2) Complete Nursing Assessment & Interventions in accordance with Individualized Health Care Plan (IHCP) Nursing Goal: Students secretions are mobilized and airway is maintained free of secretions; as evidenced by clear lung sounds and ability to effectively cough up secretions after treatments and deep breaths. Student Name DOBSchool/ District GradeParent/ Guardian PhonePhysician/ NP/PA PhoneOrder Start DateOrder Exp DateIHCP on FileICD-10 Code __ __ __ __ __ Date/TimesSuctioning TracheostomyComplications/AssessmentSignature/Title*Code Date Start Time Stop Time Secretions  Secretions Amount  Secretions ColorLung Sounds4 R L *Medicaid Procedure Code: Code T1002 RN Services up to 15 minutes Code T1003 LPN Services up to 15 minutes To be completed by Attending Provider (School Nurse/RN): NOTE: LPN must use supervising RNs NPI number Name: ______________________________________ Title: _______ NPI number: ___ ________ Name: ______________________________________ Title: _______ NPI number: ___ ________ Name: ______________________________________ Title: _______ NPI number: ___ ________ Name: ______________________________________ Title: _______ NPI number: ___ ________ 1- t= thin, TH= thick; 2- small < 5cc, m=moderate < 10 cc, l=large >15cc; 3- p=pink, y= yellow, w=white, g=green, b=brown, c=clear, bl=bloody; 4- cl=clear, r= rhonchi, cr=crackles Student Name:_________________________________________DOB:________________ Page 2. 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