GENERAL SCHOOL NURSING INFORMATION
4. Student Health Records
Student Health Records:
Student Health Records are subject to the provisions of the Family Education Rights and Privacy Act of 1974, (FERPA, PL 93-380, 20 USC 1232 (g)). Three important provisions of this Act are:
1. Access by parents to all education al records directly related to the student;
2. The right to an administrative hearing to challenge "inaccurate, misleading, or otherwise inappropriate" data in the education records; and
3. Limitations on the school's disclosure of information in the education records to third parties without parental consent.
Components of A Student Health Record:
· Individual student health folder: the name on the health folder will be the legal name. (Given name or alias will be in parenthesis.) Birth date and year. The health folder of the student completing elementary school will accompany the student through secondary school.
· Copy of student registration record.
· Copy of a signed immunization record provided by parent or guardian.
· Health Care Action Plan for a student with a significant health problem requiring specialized care during the school day or emergency care in specific situations. A copy of this plan may also be maintained in a separate desktop notebook and on the school bus if appropriate.
· Information pertinent to student health is maintained on the Win-Health computer program.
· Copies of Incident/Injury Report with attached nurse evaluation
· Copies of written correspondence with parents or documentation on progress notes of conversations with parents/guardians.
· Screening information is entered on the front of the health folder.
Forms used to document student health visits and assessments are in the computer Win-Health program.
Abbreviations and Symbols Used in Health Records:
Symbols and abbreviations listed and defined in the appendix of the Merck Manual may be used in documentation in the student health record. In addition, symbols and abbreviations commonly used in school nursing (See Appendix B) are acceptable for documentation on health records in the Humboldt County School District.
Access to Records:
Health records are stored in a locked file cabinet in the nurse's office.
Family Education Rights and Privacy Act assures parental and eligible student access to health records.
Educational staff access may be granted if they have a legitimate educational interest. Access is obtained through the nurse or principal with the nurse present to explain or interpret medical information.
A review of student record form will record persons who access a health record. This record will include the person's name, date of access, and purpose for which authorization to review the data is granted. The form will be filed as the front cover sheet to each accessed file. (See Appendix B)
State and Local Access to Records:
Representatives of the Nevada Division of Health, Department of Immunization are permitted access to health records for the purpose of auditing individual student immunization records to determine compliance with the Nevada Immunization Law.
Representatives from the local Department of Community Health may have access to immunization records in the event of a communicable disease outbreak. The purpose would be to determine the names of unprotected students, need to for further immunization follow-up, and/or possible exclusion from school during the outbreak.
Amendment of Records at Parental Request:
A parent who believes that information in health records is inaccurate or misleading or violates the privacy or other rights of the student may request that the information be amended. Amendment will be based on District Policy for correction of educational records in compliance with FERPA regulations.
The school nurse will protect the confidentiality of the student as required in the Nevada Nurse Practice Act,) NAC 632.890). Confidentiality extends to provision of nursing care as well as to personally identifiable information from health records at collection, storage, disclosure, and destruction stages.
An Authorization to Release Confidential Information (See Appendix B) must be completed and signed by the parent/guardian, student, age 18 and older whenever:
1. Another health care provider requests school Health Records.
2. The nurse or school official requests health records from another health care provider.
The requesting party is responsible to obtain the appropriate signature prior to release of records.
No medical records are released without appropriate signed authorization.
Records of Child Abuse:
Reporting of suspected incidents of Child Abuse is defined in Nevada Law. NRS 432 B.220 defines mandated reports of suspected child abuse. The school nurse, as mandated reporter will document observations and conversations that are suspicious of child abuse. Documentation will be maintained in the student health folder and will be released to persons specified by law (NRS 432 B.290) for the purposes of investigation of the event. Details of this documentation remain confidential to others in an effort to avoid compromise of the child and family's privacy.
Records of Students with Chronic Health Problems:
Records of students with chronic health conditions may include confidential records of diagnosis and treatment released to the school from hospital or other medical settings. Details of this information will not be shared with other school personnel without good cause and specific permission from the parent.
HIV Positive Student- See Humboldt County School District Policy - J.G.C.B. HIV Positive Policy.
Confidentiality and Minor's Right:
NRS 129.030 (2) allows minors, at age 16 years, to consent to some general medical treatment and health care as if he or she was an adult. Confidentiality regarding this student's health car will be maintained as under provisions of this law. However, concerns for the safety of the student and/or the school community will require sharing of the information in question with the student's parents or school authorities.
Transfer of Individual Student Health Information upon Student Withdrawal from the Humboldt County School District:
Immunization record information, results from screening of vision, hearing, scoliosis, and height/weight measurements will be forwarded to the student's new school upon request of that district and proof of parental permission for release of records.
Notation of a report to a Child Protective Agency may be shared with an administrator or nurse in another school district.
All other health information (i.e. hospital records, medical reports will remain confidential and will not be released without the specific written permission of the parent.
Transfer of A Student to Another School within the Humboldt County School District:
The student health folder, copies of Health Care Plans, and Medication Documentation Records are forwarded to the School Nurse of the receiving school. Transfer of records must be in a timely manner to prevent development of duplicate records.
Health Records placed inside the student education file and sent to the receiving school may be filed with educational records. Health records will reach the nurse if placed in a separate mailer and directed to the attention of the nurse.
Retention Schedule of Health Records Based on NAC 239.511:
· Immunization records are retained for 6 years after graduation.
· Cumulative health folders are retained until the student graduates.
· Individualized Educational Programs and parent consultations are retained for 6 years after graduation.
· Informational Correspondence is maintained for 3 years.
(See Appendix B for sample forms used in the Student Health Record.)