STUDENT CUMULATIVE HEALTH RECORDS AND DOCUMENTATION

In this Chapter . . .

•  Student Health Records
•  Documentation
•  Health Room Visit Documentation
•  Student Accident Report
•  Student Incident Report
•  Health Room End of Year Checklist
•  Medical Abbreviations

THE STUDENT CUMULATIVE HEALTH RECORD

A student's cumulative health record consists of:

•    Cumulative School Health Record (DH 3041).

•    Physical Examination Form (DH 3040).

•    Certificate of Immunization (DH 680 or DH 681).

•    Health History - collected at entrance to PreK, K, 3, 6, and 9 and new enrollees to district.

•    Health Emergency Information Cards from the last two previous years (at minimum).

•    Current and previous Health Room Visit Cards, if applicable.

•    Screening Documentation

  •  Vision (Panel L545)

  •  Hearing (Panel L548)

  •  Scoliosis (Panel L548)

  •  Height/Weight (Panel L547)

Note:  See copies of student health forms in the "Forms" chapter.

The cumulative health record should be stored in the health room under lock and key for access by health personnel.  When a student transfers to another school within the Sarasota County School District (District), the health record should be added to the student's cumulative record file.  If the student withdraws from the District, the health room aide should also include AS/400 panels L545, L547, and L548  (if they contain health screening results) in the health file.

A current Health Emergency Information Card for each student should be kept in a separate file (to safeguard student confidentiality), which is accessible to health room and office personnel in the event of an emergency.  It is important that the card is checked for up-to-date telephone numbers and physician/dentist contacts, as well as parent/guardian signature.  The school staff does not have parental/guardian permission to offer first aid or any other comfort measures without a parent/guardian signature on this card.  The card also serves as permission for mandated health screenings for students in specific grades.  If a health condition is identified, add the condition to the high risk/health concerns list and notify the school RN.  The school RN will evaluate the need for an Individual Health Plan (IHP).

Documentation

The electronic or hard copy 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.  This means that 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 AS400.  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).

•    Record promptly.

•    Describe what is seen or heard, but make no judgments.

•    No vague phrases.

•    Don't write assumptions.

•    Do not accuse, blame, or characterize any one 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.

Observation

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.

For schools that have access to the AS/400 computer system, the visits should be documented into the Clinic Visit Program.  There are several instruction guides for the various clinic programs.  These can be printed out or displayed.

Instruction Guides:

•  Using the Clinic Visit Program

•  Daily Health Services Log - Quick Reference for Clinic Program (listing of codes that can be used for each field)

•  Quick Steps for Clinic Program

•  Documenting Late Entries

•  High Risk and Health Concerns Program

  • High Risk - Health Concerns Guidelines

  • L549 Risk/Concern Panel

  • High Risk/Health Concerns L549 Codes

  • Printing High Risk and Health Concerns Reports

•  Clinic Program Statistics - How to Gather Information

Contact the Helpdesk for access to the program and training. 

 If a substitute is in the health room who does not have AS400 access and training, the visit information must be hand written on the Daily Health Services Log or similar form.  When the health room aide returns, this information is to be entered into the computer.  If records are entered into the computer, no additional information needs to be sent to the School Health office. (See Documenting Late Entries for details.)

If a school does not have AS400 computer access, the visits should be documented on the Daily Health Services Log and the Clinic Visit Card.  The information from the Daily Health Services Log is to be tallied and recorded on the Charter School Coding – Daily Services Log and sent by fax or pony to the School Health office at the Landings at the end of every week.  Contact your school RN or phone 32101 for more information.

Display/Print Charter School Daily Service Log

Display/Print Charter School Weekly Activity Log

M        Manual documentation of the health room visit must include:

•    Date.

•    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 person providing care (for manual documentation).

•    Parental notification.

•    Student outcome.

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 Incident Report

Complete a Student Incident Report when:

•    A Student Accident Report is completed.

•    A head injury occurs.

•    If unable to contact 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 Sarasota County Health Department 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:

•    Emergency cards are filed in the cumulative school health record as the new cards are received.  Retain cards from the previous two years in the health file.

•    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 chapter.  Any medications not picked up by the last day of school are to be discarded (see chapter 6).

•    The Medication/Treatment Authorization forms and Medication/Treatment Administration logs are filed in the cumulative health record.

•    Student Incident Reports are filed in the cumulative school health record.

•    Review inventory and order supplies for 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 RN

Medical Abbreviations

Click on the link below to see medical abbreviations.

Display/Print Medical Abbreviations

Last updated: 02/16/12