SCHOOL NURSE DOCUMENTATION

Arkansas Department of Health is an approved provider of continuing nursing education by South Central Accreditation Program, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation

The planning committee & faculty attest that NO relevant financial, professional or personal conflict of interest exists, nor was sponsorship of commercial support obtained, in the preparation or presentation of this educational activity.

“Accurate, timely documentation of nurse-student interactions promotes high quality student health services, advances the efficiency and effectiveness of the school and district health program, and creates a legal record. Legal and ethical considerations require school nurses to document care and keep personal information confidential and secure.” Journal of School Nursing NASN - Health information in any form must be confidential, secure, accessible only by authorized staff, and protected from loss, alteration, or destruction. If you didn’t chart it you didn’t do it. Make sure when you note information that needs to be followed up on make sure you document what you did for follow up. School health records provide the mechanism for a school nurse to communicate information to students, families, the school multidisciplinary team, emergency personnel, other healthcare providers, and school nurse substitutes. Data from school health records can show evidence of student health problems that should be addressed. Data are also used for evaluation of school health programs, quality assurance, disease surveillance (Calman, Hauser, Lurio, Wu, & Pichardo, 2012) and evaluation of program outcomes. The large caseloads and volumes of longitudinal student information collected by school nurses result in a quantity of data that is not readily managed by paper processes. Electronic documentation systems allow for efficient data management processes including the documentation, reporting, and analysis of student health data. Electronic data management systems also allow for the aggregation of data from multiple sources if the data elements are standardized across systems.

Safe and accountable nursing practice requires adherence to the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) and systematic, Continuous documentation of the individual care provided to clients.

In school nursing, documentation is the written record of Interactions between and among school health professionals students and their families other members of the health care team community health care providers Administration of educationally related/medically ordered • Screenings • Procedures • Treatments • Student and family education • Results or response to interventions • Evidence that the nursing process was used to deliver care

Every Student should have a chart Student Medical Chart Every Student should have a chart in the nurses office. First of all there needs to be a chart on EVERY student, kept in the nurses office! The secretary does not need health records in her files.

What to include in all charts: Name and DOB on tab Student information sheet Birth certificate-possibly Official paperwork stating name change and/or adoption Official notifications stating a parent/grandparent, etc is not allowed to pick up child Official Immunization record- Medical Information Form-MIF Screening results Episodic health room care Previous Medication Administration Records-MAR Correspondence with physician Correspondence with parent/guardian For future reference on official records the nurses need to retain a copy of proof of adoption or name change. I have called a parent thinking they were custodial when in fact they have had visiting rights revoked and I didn’t know it. We appreciate all of their help but we are there to do our job. So they don’t need to do it for us.

What to include for chronic health conditions: Individual Health Care Plan - IHCP Emergency care plan Daily treatment and response Data for students with conditions such as asthma; severe allergies; seizure disorders; and Type I Diabetes.  Health care training/certificate for that child

HIPAA and FERPA

HIPAA Health Insurance Portability and Accountability Act of 1996 Created to protect the privacy and security of individually identifiable health information and give patients increased access to their medical records HIPAA's privacy rules allow covered healthcare providers to disclose personal health information about students to school nurses, physicians, and other healthcare providers employed by a school district for treatment purposes, without the authorization of the student or the student's parent. For example, a student's primary care physician may discuss the student's medication and other healthcare needs with the school nurse, who would administer the student's medication and provide care to the student while the student is at school.

FERPA Family Educational Rights and Privacy Act – Federal Law - Protects the privacy of students’ educational records - Must afford parents access to their children’s educational records and amend them if needed - Provides some control over the disclosure of information from the records - Effects all public school districts and most private and public post-secondary schools (federal funds) If the student is 18 or attends a postsecondary school, the student is afforded these rights, not the parent

At the elem and secondary level, a students health records (including immunization records) are maintained by an educational agency or institution and are subject to FERPA Records that a school maintains on special education students (including records or services provided to students under IDEA are FERPA SN role is to become educated and stay current; provide education to administrators and colleagues; educate parents and students; provide staff training; ensure health room procedures, records and equipment provide security and privacy of health records And…ensure appropriate internal sharing for “legitimate educational purposes”. Annual screening results can go to student’s permanent school folder, not meds, tx, etc.

Individualized Education Program (IEP) An IEP is a legal document. It spells out a child’s learning needs, the services the school will provide and how progress will be measured. Collaborative process – input across disciplines - include parents in development Plan ensures necessary services (related services) are provided to the student (such as speech therapy)

Development of the IEP Nurse’s role may be to review medical records for inclusion into the plan Example of a related service/nursing intervention may be urinary catheterization Plan should include what is best for child – not convenient for school Special Education Coordinator or LEA responsible for facilitating process IEP can be changed (programming conference) based on changing needs of student but committee must be convened Transition services/planning begins at age 14. Transition services should be addressed at 1st IEP after student’s 16th birthday Should speak to post secondary goals such as employment, training, education and independent living Moves child from school to post school activities Child must be invited for transition

Composition of IEP Statement of the child’s present level of academic achievement and functional performance Statement of the student’s annual goals Statement of specific education – including participation in general education programs Relevant medical records Related services (i.e. transportation)

Related Services Requires physical evaluation May require a physician’s prescription Prescription does not guarantee services – it is the committee’s decision 2 landmark cases on related services - 1 child with SB who needed CIC and other case involved student who was vent-dep – both determined that student’s access to FAPE required services (related) of a school nurses

504 Plan Legal document Assist students with impairments within regular education setting Allows students to receive accommodations within regular education setting Eligibility based on whether condition interferes with certain major life activities (ADL’s) – walking, eating, toileting May include students with sensory impairments Amended in 2008 - clarifies that an impairment that is episodic or in remission is a disability if it would substantially limit a major life activity Accommodations are not always appropriate during achievement (benchmark) testing

504 Eligibility Students who do not qualify for IDEA may still need specialized services & are thus protected under a civil rights provision Referred by parent, teacher, doctor, school nurse Every school district must have designated 504 Coordinator Parents or guardians must be advised of their rights Eligibility is determined by team with decision based on assessment , medical records and input from parents, teachers and health professionals 504 result of the Civil Rights Movement – discrimination issue. No funding allotted for programming. New focus on advocacy now – attorneys more involved – families better informed. Ex – Wickes. What happens if school not in compliance? Mediation first. Can be referred to Office of Civil Rights. Ultimately, district could lose federal monies.

Examples of 504 Eligible Dx. Asthma Diabetes Epilepsy Cystic fibrosis HIV/AIDS Mental illness Spina bifida A 504 plan spells out the modifications and accommodations that will be needed for these students to have an opportunity perform at the same level as their peers, and might include such things as wheelchair ramps, blood sugar monitoring, an extra set of textbooks, a peanut-free lunch environment, home instruction, or a tape recorder or keyboard for taking notes.

What 504 Plan Should Address: Medical and/or nursing diagnosis Accommodations (such as moving child with hearing impairment to front of classroom, or adjusting school lunch menu) Outcomes (to prevent complications) Impact of the handicapping condition on ability to perform ADL’s Medications

Individual Health Care Plan (IHCP) Guiding force behind nurse’s actions Adapted specifically for school setting Provides clear path to desired outcome Appropriate if child has health concerns to be addressed or needs nursing care IHCP or IHP will be more detailed than IEP as far as health issues Requires collaboration Requires thorough assessment May need emergency component Discussion of emergency plan – concise, brie plan with easy access for appropriate parties

NASN Position Statement It is the position of the National Association of School Nurses that students whose health needs affect their daily functioning have an IHP. It is also the position of NASN that the professional school nurse should be responsible for the writing of the IHP in collaboration with the student, family, and health care providers and for seeing that the IHP is implemented, with periodic evaluation for evidence of desired student outcomes.

Why IHP Is Needed Medications Special diet Health maintenance Adaptation of health education program Adaptation of health screening procedures Special physician orders for care Special training of school personnel Change in school environment Safety measures Measures to relieve pain Self care assistance Rehabilitation measures Importance of Care Planning Quality assurance of school nursing services Continuity of ongoing care in the school environment Development of a safer delegation process of nursing in the school setting Arkansas State Law ACA § 6-18-1005 (a) ASBN (May 2000) NASN School Practices (1998)

Steps to Creating IHP Nursing Assessment Nursing diagnosis (NANDA) Nursing interventions (NIC) Outcomes (NOC) Evaluation of plan

Assessment Data for IHP Development Includes: Required screenings (vision, hearing, scoliosis, and immunizations) Observations of the student for development and health patterns Communicable disease monitoring Assessment of school environment for potential health and safety hazards Assessment of family’s needs related to student’s healthcare requirements Accurate health and developmental history of student

Prioritizing Goals/Outcomes Priority Goals Life Threatening Circumstances (ECP) Basic Needs Cause of greatest distress to student Situation/Problem which, if managed first, will help directly/indirectly resolve the other concerns. Minimal Goals Student will consistently and actively participate in school programs Student will implement personal actions to palliate/eliminate pathology/safety risks/health threats

Monitoring IHP Reviewed and updated at least annually or more often as appropriate – noted with nurse’s signature and date May need regular communication with health professionals and parents Skills performed by other school staff for student may require periodic demonstration of competency Refer to state board document/guidelines.

Emergency Care Plans Set of procedural guidelines that provide specific instructions about what to do in an emergency situation Student may need both IHCP and ECP ECP should be readily accessible for school personnel Plan should have specific information about child’s medical condition, medications – current and emergency, and appropriate emergency interventions ECP will be concise with limited confidential information included.

Examples of IHP

Allergy

Seizure

Diabetes

Asthma

Addendum Some longer care plans may not require a complete redo or any changes at all. So this Addendum sheet is a great tool to bring it up to date with new signatures and new dates on it.

Care plans Don’t make it harder than it is! Signed by physician, RN, parent/guardian No need to reinvent every time. Keep blank copies on hard drive or flash drive and make copies as needed. Can be faxed to doctor for signature and returned via fax as well. One notebook with different sections for Allergies / Asthma / ADHD-ADD / Chronic Headaches / Seizures. I placed a copy of the care plan in this book with original in student folder with all signatures. Again use page dividers to separate each condition from the others. File alphabetically if you want. Tabs may vary. Depending on census, number of students with specific, nurse preference.

Arkansas State Board of Nursing National Association of School Nurses New Mexico School Health Manual Texas Guide to School Health Programs The School Nurse’s Source Book of Individualized Healthcare Plans – Volumes 1& 2

Notebook system This add to easier transitions from school year to school year and for sub nurses (when they are available). And it keeps the nurse from handling so many charts and papers all day long

Notebook system A notebook system can be used for office organization: *Vision *Hearing *Care Plans *Head Lice *Immunizations *Diabetic Students The district I was in made the care plan book a “red” book. So if another nurse came in to work for me I could leave her instructions to just look in the “red book”.

Vision and hearing *Keep together or separately *First section is your referral log, Second section contains copies of the referral letters you have sent home Third section contains copies of current laws Fourth section contains blank copies of referral letters, etc. *Can place vision in front and hearing at back or keep 2 separate binders. Use page dividers, these are cheap. But if the district won’t buy them I used file folders cut I n half and holes punched in them.

Immunizations First page, the log of deficient students Secondly, the copies sent home informing parents of date of notification and date that student will not be allowed in school At the back should be current copy of the law with the regulations Keeping the copies of your letters home provide you with great documentation of the parent notification(s). You can also print out from Cognos.

Head lice Use Log of student’s checked in front—include date, teacher or room number, if found nits or live bugs, treatment, date of recheck for return to school and initials of person rechecking. Next I included a blank copy of the district form letter so I had it handy to use. Can include copies of what to do for an infestation of head lice to give to parents as well or place on back of form letter.. Most schools continue to have a no nit policy. However, that is not what is recommended by CDC and AAFP. Just keep this in mind as your career as a school nurse continues. NASN position statement and sample policy Remember other bugs bed bugs ring worm scabies/body lice

Head lice log

Medication Administration The School Nurse is responsible for the administration of medications RN can identify qualified personnel to be trained and delegate med administration to the UAP **Handout for Act 1694- Students carry epipens and asthma inhalers

Medication Administration School Medication Administration Policy Act 1694-Students carry/use inhalers and epipens Proper Storage of Meds ADHD Meds First Dose of Meds Disposal of Unused Meds

Medication Administration Original container Current pharmacy label (MD order) with Students Name, Medication Name, Dose and Frequency, Physicians’ Name and Date Follow label directions only Parental consent

Rectal Diastat Used in case of prolonged seizure Only to be administered by a nurse or parent of the student School and state policies

Respiratory Inhalers and Epi-pens Act 1694 of 2005 “Alex’s Law” Requires school districts to allow students to carry and use Rx asthma inhalers and epipens while in school, at on-site school sponsored activities, and at off-site school sponsored activities; and for other purposes Use of Epi-pen is medical emergency and requires 911 call

Mar-front Notice there is a brief description of the district medication policy at the top of the form followed by the parent/guardian permission area. At the bottom is the area the nurse and the parent/guardian complete together with medication count, etc. There is also an area for the parent/guardian and school nurse to count the meds together and then sign.

This was copied onto the back of the initial permission form This was copied onto the back of the initial permission form. Notice the dates that school is not scheduled are blacked out. There is an area for 1 change to be made to the dosing at the top. Signatures of all dispensing the med, parent signature for intake of med is at the bottom. A place to count the meds as they come in with the parent/guardian and then place initials are on the side.

Add Epi form Form completed online. Epi training coming. Person that gives epi fills out form, Nurse reviews and enters electronically

Add Glucagon form Nurse must complete and sign regardless of who administers

Immunizations

Add ADH link

Add hyperlink to Word document

Immunization log

Immunization Deficiency letter (sample)

Immunization Exemptions There are 2 types of exemptions in Arkansas as of 2003 (Act 999) Medical Non-Medical (Religious and Philosophical) Only granted by the Arkansas Department of Health (ADH). Request forms through the ADH Immunization Section (501-661-2169) Look up website

All Exemptions Require: An annual application A notarized statement sent to ADH requesting the exemption Completion of an educational component. A signed statement of “refusal to vaccinate”’ Understanding that child will be removed from school during an outbreak (up to 21 days from last case) and not allowed to return until outbreak is deemed over by the ADH.

Arkansas WebIZ Name change – from the Immunization Network for Children (INC) to Arkansas Web IZ. System became available in June 2013. https://adhimmreg.arkansas.gov/webiznet_adh _test/Login.aspx Look up immunizations based on child name and date of birth. Print an official immunization report for each child and place in child health folder.

Responsibility for Enforcement School boards, superintendents and principals shall be responsible for enforcing immunization requirements for K- 12. May temporarily admit a child provided the child becomes appropriately immunized, is in-process of receiving the needed doses of vaccine, or shows proof that they have applied for an exemption for those vaccines he/she has not received within 30 calendar days after the original admission. Must have written statement that the student is in process. If no documentation, they must be excluded until documentation is provided.

Special Health Care Needs Paraprofessional Module “Facilitator Training” http://www.arkansascsh.org/

Generally speaking Retain written records on students for 5 years after proposed OR actual date of graduation. A doctor signature IS NOT required on a MAR when the current prescription bottle is in the nurses’ office. (Which it should be at all times) E-school will store all of your data, therefore there is no need to keep a hard copy. However, do not destroy your handwritten information until you are completely sure that you have entered everything completely! Organization IS THE KEY. Use folders, binders, sorting trays, etc.

School Nurse Survey Annual School Nurse Survey Link is on www.arkansascsh.org

The end Have a great year. You are the voice for the children, speak loudly when needed.