Question:  Can the screening results reported on a physical (Health certificate) be recorded as the mandated screening for the school year?

Answer: If the physician, nurse practitioner or physician’s assistant notes the screening results in a manner that you can be reasonably sure that an adequate screening has been completed, you may transcribe the results from the physical to the student’s cumulative health record.  The student would not need to be screened again at school.

 

The examiner would need to note the Vision Screening results as follows:

“20/20 R, 20/20 L” – or something in a similar format rather that just writing “Pass”.

 

Hearing screening should read:  “Pass 20 db sc” for the screening so that you know that a sweep check was done at 20 decibels.  If the examiner simply writes “Pass” you can’t be sure of what screening was done and the reported results should not be used for the school screening.

Question:  Should the BMI that the health care provider is/will be reporting to the school be recorded on the Cumulative Health Record?

Answer: Yes, all information provided to you by the private health care provider should be recorded on the Cumulative Health Record.  In the case of BMI, both the BMI reading and the BMI percentile (weight status category) should be recorded.

Answer:  No You need to keep a Cumulative Health Record for each student but there is not one required form for the state. 

We have an updated form that you can customize for your district's use in our website's School Nurse Tool Kit - found  at: http://schoolhealthservices.org/tool_kit.cfm?subpage=96 (scroll down to "Cumulative Health Record")

 

Question:  Are health records considered part of a student's education records? 

Answer:     Yes, education records include information directly related to a student that is maintained in any recorded way.  Medical and health records that the school created or collects and maintains are considered to be part of the student's academic record.

Resource:  Records Retention and Disposition Schedule ED-1; Revised 1997, The University of the State of New York, The State Education Department, State Archives and Records Administration, Local Government Records Services, Albany, NY  12230

 

Question:  What are the basic considerations in managing school health records?

Answer:  The following issues should be considered in school health records:

§         Nursing documentation should be accurate, objective, concise, thorough, timely, and well organized.

§         All entries for paper records should be legible and written in ink that can be photocopied easily (black ink is recommended).

§         The date and exact time should be included with each entry.

§         Documentation should include any nursing action taken in response to a student’s problem.

§         Assessment data should include significant findings, both positive and negative.

§         All records, progress notes, individualized health care plans, and flow charts should be kept current.  The current individualized healthcare plan should be marked as “part of the permanent health record”.  Standardized healthcare plans are acceptable as long as they are individualized to each student’s condition and needs.

§         Documentation should include only essential information; precise measurements, correct spelling, and standard abbreviations should be used.

§         Only facts (objective data) relevant to the student’s care should be recorded; personal judgments and opinions of the nurse should be omitted (i.e., “the student is breathing normally” is an opinion, whereas the notation “respirations 20/min; no retractions, rales or wheezing” provides objective data).

Question:  What should a school nurse do when an error is made in recording on a school health record?

Answer:  When an error is made, one single line should be drawn through the error; the word “error” and the nurse’s signature should be written directly above it.  The correct entry should then follow.  Words should never be erased, scratched or whited out.

If an entry is made in the wrong student’s record, the entry should be marked, “mistake in entry” and a line drawn through the mistaken entry, and proceed as outlined above.

Late entries should be avoided.  When necessary, a late entry may be added, but in the correct date and time sequence (i.e., write today’s date when entering a note related to care provided yesterday afternoon and mark it “late entry”).

Question:  Where is information about retention of health records found?

            Answer:  The information is available from the State Education Department in our A-Z Index under "R" for records retention at:

http://www.schoolhealthservicesny.com/uploads/Records%20Retention%202004.doc  

Question:  What additional issues are related to computerized or electronic health records?

Answer:   School nurses should use student health databases that allow information to be recorded in “real time” (at the point of care).  Additional considerations include:

§         Maintain confidentiality through restricted access to student health records.  Different school personnel can be assigned different access to the program through multi-level passwords (i.e., the school nurse should have access to read and write into the records, the school secretary and school administrator may have “read only” privileges, and most school personnel would have no access to records).

§         School Nurses should use screen savers in the event that they are called away from their desks while student records are open.  Some screen savers can only be removed with a password, which offers the maximum protection of the records.

§         Electronic records should always be protected and “backed up” on a regular basis.  Records should also contain a mechanism that does not allow an original record to be altered or erased.

Resources:

Guidelines for School Nursing Documentation: Standards, Issues, and Models,  Nadine C. Schwab, Mari Jo Panettieri, Martha Dewey Bergren, National Association of School Nurses, 1998.

Website of the New York State Education Department,www.nysed.gov.