Student Date of Birth Grade School

Parent/Legal Guardian Cell # Work # Home #
Healthcare Provider Phone # Teachers

Encopresis is involuntary passage of stool secondary to chronic constipation and distended lower bowel.

Goals of school care

·  Support in developing bowel routine while also under medical care.

·  Refer if no medical assessment has been done.

·  Reassure and educate parent.

·  Minimize physical and emotional distress for the student.

·  Prevent exposure of others to feces.

·  Minimize lost class time and absences for this problem.

·  Educate student, family, and staff about this condition and the importance of medical assessment, diet, and bowel routine.

Health Accommodations/Observations

Actions / Explanations/Reasons / Who needs to know
Allow bathroom use as needed, student may need a schedule.
/ Children with this condition must relearn to recognize and respond to urge to empty bowel. May be using laxatives at home. May be on a schedule. / All staff who work with this student, student, parent
May use bathroom in nurse’s office. / Privacy, time needed, clean up supplies are kept there.
Education and support from nurse. / All staff who work with this student, student, parent
If student has odor, refer to nurse. / Condition can cause bowel incontinence. / All staff who work with this student, student, parent
Refrain from criticism, shaming. / This is a health problem requiring support, understanding, and medical intervention. / All staff who work with this student, parent
Change of clothes will be kept in the nurse’s office.
/ Condition can cause bowel incontinence. / All staff who work with this student, student, parent
Educate and support the parent and child. / This is a physical problem, but easily misunderstood resulting in guilt and shame. / Nurse
Report BM’s at school to parent via a note or chart.
/ Part of medical management is keeping track of BM’s and intervening if the child gets constipated. / Nurse, student, parent
Follow treatment plan as directed by healthcare provider:______/ Medical interventions may be ordered for student. / All staff who work with this student, student, parent

To be completed by the Healthcare Provider Diagnosis:

Treatment recommendations/directions for school staff:

Healthcare provider [print name]: Signature: Date:

To be completed by the Parent/Legal Guardian

Comments/notes for school staff:
Parent/Legal Guardian Signature: Date:

To be completed by School Nurse – Reviewed/communicated to designated teachers, support staff, administration, and auxiliary staff.
Signature of School Nurse: ______Date: ______School Year:______

File original in Individual Health Record; Copies to appropriate staff and Emergency Action Plan Notebook Revised Oct. 2015