Student Health Records and Documentation
In this Chapter
- Student Health Records
- Health Room Visit Documentation
- Student Accident Report
- Student Injury Report
- Health Room End of Year Checklist
- Medical Abbreviations
The Student Cumulative Health Record
A student's cumulative health record consists of:
- Physical Examination Form (DH 3040)
- Certificate of Immunization (DH 680 or DH 681)
- Health History - collected at the entrance to PreK, K, 3, 6, and 9 and new enrollees to the district (may be electronic)
- Emergency Contact information can be printed from SIS
- Parental Consent for Health Services (may be electronic)
- Screening Documentation on SIS Health Program
There will be a Parental Consent for Health Services in Info Snap for students that have been registered or re-registered online. For manual registration, a paper copy is available. The school staff does not have parental/guardian permission to offer first aid or any other comfort measures without a parent/guardian electronic signature. This form also serves as permission for mandated health screenings for students in specific grades. If a health condition is identified, add it to the high risk/health concerns list and notify the school nurse. The school nurse will evaluate the need for an Individual Health Plan (IHP)
The electronic health record is a confidential and legal document. It provides a form of communication for documenting activities/conditions relevant to the child's health. It is important to remember to write down or record what you observe and what you do. This documentation is admissible in a court of law, meaning anything you write or enter into the electronic record is considered to be true. If you do not record something that you did, it is assumed that it was not done. There are some general guidelines for documentation that everyone must follow:
- Confidential or sensitive information (i.e., student discussing suicidal thoughts, pregnancy, etc.) is not to be recorded on the SIS Health program. This information should be kept in a confidential locked file. This file will serve as a record indicating that the situation has been addressed as well as protect sensitive information. If in doubt, contact your principal and school RN for guidance on what information should be documented in the confidential file. Also, consult your principal for file storage procedures in your school.
- Use day, month, year, time of day, and your signature (initials are OK if your signature is identified on the page with your initials).
- Never erase or use liquid correction fluid ("white out").
- Use authorized abbreviations (see Medical Abbreviations in Forms Section).
- Records must be entered daily.
- Describe what is seen or heard, but make no judgments.
- No vague phrases.
- Don't write assumptions.
- Do not accuse, blame, or characterize anyone in your documentation.
- Never refer to an accident report that has been filed.
- Never write or enter into the electronic record care or observations ahead of time.
- Don't leave blank spaces on forms.
- Correctly identify late entries (for manual documentation).
- Correct mistaken entries properly.
When interacting with the student, use all of your senses to evaluate the situation.
Look Listen Feel Smell
There are two types of observation:
Subjective observation cannot be seen. They are ideas, thoughts, or opinions about the student. If you cannot see it, hear it, or smell it, it is a subjective observation. (The student complains of a headache - you cannot see it.)
Objective observations can be seen. If you see, feel, hear, or smell it, it is an objective observation. (The student has a cut - you can see it.)
Health Room Visit Documentation
All student visits to the health room need to be documented. All visits must be documented on the SIS Health Program. Contact the Help Desk for access to the program and training.
If a substitute is in the health room who does not have SIS computer access and training, the visit information must be handwritten on the paper Daily Health Log. Document medication administration on Medication Treatment Administration log (see Medication/Treatment Administration Guidelines Chapter.
When the health room personnel returns or the computer is available, the services need to be entered into the SIS Health Daily Log. In the Notes section, type; "Late entry- Sub record entered by (HRA or nurse initials)." (Note this is in addition to what you would normally enter into the Notes, i.e., number of carbs, etc.
Manual documentation of the health room visit must include:
- Time in and time out
- Name of child
- Complaint (if Injury, note type, and location)
- Description of signs and symptoms
- What has been done for the child (i.e., lay down 15 min. - felt better; returned to class at 8:30; sent home at 1:30, etc.)
- Initials and signature of the person providing care (for manual documentation)
- Parental notification
- Student outcome
Health Guides and Reports
The following documents can be found in the Forms Section.
SIS High Risk and Health Concerns
- High Risk/Health Concerns Guidelines
- High Risk/Health Concerns - How to Enter a Health Concern
- High Risk/Health Concerns SIS Health Condition Panel Codes
- High Risk/Health Concerns - How to Run a Health Concerns List
- High Risk/Health Concerns - How to Run a High-Risk List
SIS Other Health Reports
- SIS Reports - General Information
- How to Run the FL - Daily Health Log
- How to Run the School Health Annual Report for Your School
Student Accident Report
- Forms available from the Risk Management Office
- Follow school board policy when completion of this form is necessary
- Do Not place a copy in the student's Cumulative Health Record
Student Injury Report
Complete a Student Injury Report when:
- A Student Accident Report is completed
- A head injury occurs
- If unable to contact the parent or guardian of an injured or ill child
If a wound occurs, review the date of the last tetanus toxoid (DTaP, Td, or TDaP) administration. Notify the family of this date and advise them to consult their licensed health care provider or Florida Department of Health in Sarasota County to determine whether a tetanus toxoid booster is needed.
Health room checklist for the end of the school year
The following tasks should be completed at the end of the school year to prepare the health room for the upcoming year:
- Contact parents two weeks before the last day of school to pick up their child’s medications. A Medication Pick-up Notice is in the Forms section. Any medications not picked up by the last day of school are to be discarded (see Medication/Treatment Administration Guidelines).
- The Medication/Treatment Authorization forms and Medication/Treatment Administration logs are filed in the cumulative health record.
- Student Injury Reports are filed in the cumulative school health record.
- Review inventory and order supplies for the upcoming year.
- Pack clinic supplies and store in a secure location. Clear all surface areas in preparation for summer cleaning.
- Discard leftover items in the refrigerator.
- If your school is a summer school site or if you know that some of your students will attend summer school, be aware that copies of the Medication/Treatment Authorization Forms and Medication/Treatment Administration Logs will be needed. Medications are to be delivered to the summer school site by the parent. If you have any questions, contact your school nurse.
See Forms Section for a list of Medical Abbreviations