School nurses know how important it is to keep an accurate health file on each student. Health information that is easily available, up to date and accurate can be lifesaving. Whether your school maintains electronic medical records or paper files, it’s essential to make sure your student files are organized.
As with all health records, maintaining confidentiality is also critical. Be sure that you are following school policies and federal laws when sharing any medical information. There may be instances where you need to share pertinent health information with other staff, but that does not mean a staff member, such as a teacher, should have access to the student’s entire health record.
When putting together a student’s health record, the information needs to be accurate and objective to allow the school to meet the health requirements of the child. A health record should include the following:
Health history: Information regarding the student’s health history should be included in the health record. The information should be completed by parents or guardians. The health history should also include any health records from other schools the child attended.
Immunization record: Most schools have policies regarding immunizations required for students to attend school. You also need to keep any immunization waivers that are signed by parents refusing vaccines.
Physical: If a student is required to have a physical on file to play sports, make sure you include it in the health record. Some schools require a new physical signed at the start of each school year to play sports. Make sure you check your school policies, so health records are current.
Consent to treat: At the start of the school year, be sure each student has a consent to treat form signed by their parent or legal guardian on file.
Prescription medications: Laws vary by state on whether school nurses can administer medication that a student has a doctor’s prescription to take. Some states allow schools to set their own policies. Other states allow school nurses to administer medication only if the child cannot self-administer. Check with your district to determine your school’s policy. If a child has prescription medication, make sure information on the drug, dosage, and frequency is in the child’s record.
Medical referrals and recommendations: Document information on any medical referrals or recommendations you have made for a student. Also, follow your school’s policy for charting any medical incidents or treatment a child receives while at school.
Action plan (optional): An action plan is the information which is needed to treat a student for a condition they have. The plan helps teachers, staff, and school nurses be prepared to deal with a student’s complex health needs. An action plan is usually only needed if a student has a chronic medical condition, such as diabetes, asthma, or epilepsy. The plan provides treatment guidelines, which helps everyone involved have a better understanding of what to do if the need for treatment arises. For example, if a student has asthma, an action plan may include which inhaled medications to administer if the child has a severe asthma attack.