EPILEPSY MANAGEMENT PLAN

Information About Seizures

Description of epileptic seizures: (Describe what this persons seizures look like, duration, frequency
and usual resolution)






Identified risks, triggers, warning signs, and safety factors:
List known triggers and how to minimise:



List known warning signs:



Prevention of injury to self or others during seizure activity:



Dentures: YES NO Procedure:

Helmet: YES NO Procedure:
Additional steps to help client recover:








Does this person experience status epilepticus (continual seizures): Yes No
Name: Date:

DOB: Date of Review:

Address: Staff name & sign:



EPILEPSY MANAGEMENT PLAN




Describe how to recognise if the client is in status epilepticus:




Is medication prescribed as needed for status epilepticus? Yes No

Name and dose of medication:

Has this medication been charted on an MDNSW Medication Chart?
Yes No
When is it to be administered?

How many minutes following seizure commencement?

How is it to be administered?

Who is to administer it?

AN AMBULANCE MUST ALWAYS BE CALLED IF STATUS EPILEPTICUS OCCURS THAT IS SEIZURES THAT OCCUR
CONTINUOUSLY OR SEIZURES LASTING LONGER THAN 5 MINUTES.



When should an ambulance be called?
If the seizure is longer than 5 minutes an ambulance must be called.
If client stops breathing.
If client is in status epilepticus (continual seizures).
If the seizure happens in water.
If client remains unconscious (not responsive) after the seizure ceases.
If client has been injured.
If client is not known to have epilepsy.
Other:










EPILEPSY MANAGEMENT PLAN


Who must be advised when seizures occur?
Advise Parent / Guardian of all seizures: Yes No
If no please specify the circumstances you would like to be contacted under:


Parent / Guardian will be advised of all seizures requiring transportation to hospital

Advise program coordinator / manager of all seizures requiring transportation to hospital

Advise program coordinator / manager of all seizures resulting in an injury and complete Incident
Report



Client must be supervised at all times when swimming
Client must be observed at all times when bathing (showering)
When the client is bathing bathroom door must be left unlocked


EMERGENCY CONTACTS

Name: Relationship:
Telephone: (H) (W) (M)
Name: Relationship:
Telephone: (H) (W) (M)
Name: Relationship:
Telephone: (H) (W) (M)


PLAN APPROVED BY

Client (if informed consent):

Print Name

Signature

Date:
Parent/Guardian:

Print Name

Signature

Date:
Neurologist:

Print Name

Signature

Date:
General Practitioner:

Print Name

Signature

Date:
Program Manager:

Print Name

Signature

Date:



EPILEPSY MANAGEMENT PLAN



SEIZURE CHART

Clients Name: Year:

Record each seizure in the appropriate date box.

If type of seizure is unknown, use the letter S to record a seizure. If the seizure type
is known, use the following codes to identify the seizure type:

A. Tonic-Clonic B. Absence C. Complex partial
D. Atonic E. Myoclonic F. Status Epilepticus


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EPILEPSY MANAGEMENT PLAN