• Campus

  • Campus Nurse Name

  • Conducted by

  • Date Conducted

Medication Administration FFAC (local)

  • Principal designee for medication administration form completed and filed in Medication binder

  • Permission forms from parent/MD completed and filed in Medication binder

  • Medications organized and stored according to CFISD policy

  • All emergency medications are stored in unlocked cabinet marked "Emergency Medications"

  • Permission for self-administration of medication completed and filed in appropriate binder

  • Administration of medication is documented daily in electronic medical record (EMR)

Office Visit Documentation

  • Thorough and appropriate documentation of assessment in narrative section of daily log entries

  • Thorough and appropriate documentation of interventions in narrative section of daily log entries

Immunization Documentation

  • Immunization compliance report is up to date (as medically possible)

  • Immunization exemption certificates and MD letters are filed in Exemption binder and documented in EMR

  • Documented parent/guardian notification of immunization requirements

  • Documented notice to campus administration concerning immunization non-compliance


  • Vision and hearing screening completed 120 days from student enrollment

  • Spinal screening completed 120 from student enrollment

  • Documented monthly biological calibration of audiometer

  • Demonstrated knowledge of community assistance for vision exams including documented referrals when appropriate

Clinic Management

  • Clinic is orderly and free of clutter

  • Supplies are easily accessible

  • Otoscope, pulse ox., thermometer, and sphygmometer are in working order

Substitute Notebook

  • Organized according to CFISD guidelines found in health services handbook

  • Updated with current campus specific information including substitute spare key location

  • Current telephone lists with nearest campus RN phone numbers included

  • Current campus Alert roster included

Special Services

  • Documented campus staff health awareness education

  • Documented transportation health awareness education

  • Current IHPs for identified students

  • Current orders (updated annually) for special procedures in appropriate binder

  • Documented training for delegated procedures<br>

  • Documented supervision of delegated procedures

  • Principal UDCA delegation form signed and filed in Diabetes binder

  • Documented UDCA training filed in Diabetes binder

Emergency Preparedness

  • Evacuation plan in place

  • Emergency trauma bag properly stocked and easily accessible

  • Rolling wagon to evacuate medications is easily accessible

  • AED checklists current (inspected monthly)

Audit Results

  • Is follow up audit necessary?

  • When will follow up audit take place?

  • Auditor's Signature

  • Additional Remarks

  • Campus Registered Nurse Signature

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