• 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

  • Controlled Substance log documentation

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

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

Office Visit Documentation

  • Are clinic passes used for each student?

  • 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 (where applicable)

Clinic Management

  • Comments

  • Clinic is orderly and free of clutter

  • Supplies are easily accessible

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

Substitute Notebook

  • Organized

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

  • Current telephone lists with nearest campus RN/LPN phone numbers included

  • Current Campus Code Blue Procedure Plan Listed

Special Services

  • Current IHPs for identified students

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

  • Documented training for delegated procedures<br>

Emergency Preparedness

  • Evacuation plan in place

  • Emergency trauma bag properly stocked and 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 Nurse Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.