Richardson ISD Clinic Visit Report 2019

• Richardson ISD Clinic Visit Report

• Nurse:

• Area assignment:

  Berkner

  Lake Highlands

  Pearce

  Richardson

• School:

  Select Berkner HS Liberty JH Apollo JH Audelia Creek Big Springs Christa McAuliffe LC Dartmouth Forestridge Jess Harben Mark Twain MST Magnet O'Henry Terrace Richland Springridge Yale Support Nurse Memorial Park

  • Berkner HS
  • Liberty JH
  • Apollo JH
  • Audelia Creek
  • Big Springs
  • Christa McAuliffe LC
  • Dartmouth
  • Forestridge
  • Jess Harben
  • Mark Twain
  • MST Magnet
  • O'Henry
  • Terrace
  • Richland
  • Springridge
  • Yale
  • Support Nurse
  • Memorial Park

• School:

  Select Lake Highlands HS Lake Highlands Freshman Center Forest Meadow JH Lake Highlands JH Aikin Forest Lane Academy Hamilton Park Pacesetter Magnet Lake Highlands Elem Merriman Park Moss Haven Northlake Skyview Stults Road Thurgood Marshall Wallace White Rock Support Nurse

  • Lake Highlands HS
  • Lake Highlands Freshman Center
  • Forest Meadow JH
  • Lake Highlands JH
  • Aikin
  • Forest Lane Academy
  • Hamilton Park Pacesetter Magnet
  • Lake Highlands Elem
  • Merriman Park
  • Moss Haven
  • Northlake
  • Skyview
  • Stults Road
  • Thurgood Marshall
  • Wallace
  • White Rock
  • Support Nurse

• School:

  Select Pearce HS North JH Parkhill JH Bowie Brentfield Intermediate Brentfield Primary Canyon Creek Greenwood Hills Mohawk Northrich Prairie Creek Prestonwood Support Nurse

  • Pearce HS
  • North JH
  • Parkhill JH
  • Bowie
  • Brentfield Intermediate
  • Brentfield Primary
  • Canyon Creek
  • Greenwood Hills
  • Mohawk
  • Northrich
  • Prairie Creek
  • Prestonwood
  • Support Nurse

• School:

  Select Richardson HS West JH Westwood JH Arapaho Classical Magnet Carolyn Bukhair Dobie Primary Dover Northwood Hills Heights RISD Academy Spring Creek Spring Valley Support Nurse

  • Richardson HS
  • West JH
  • Westwood JH
  • Arapaho Classical Magnet
  • Carolyn Bukhair
  • Dobie Primary
  • Dover
  • Northwood Hills
  • Heights
  • RISD Academy
  • Spring Creek
  • Spring Valley
  • Support Nurse

• Date/Time:

  Date

• Visit Completed By:

  Becky Geise, Lead Nurse

  Mandi Holton, Team Leader

  Kelly Wicker-Wilson, Team Leader

  Shannon Duncan, Team Leader

  Kim Clark, Team Leader

• This visit was:

  Routine

  Requested by principal

  Requested by RN supervisor

  Requested by RN

Clinic Environment

• Clinic is a nonhazardous environment (free of spills, clear traffic pattern, body fluids cleaned immediately).

  Yes

  No

• Emergency Bags are easily accessible and properly stocked.

  Yes

  No

• Is the 2nd Emergency bag stored in a location away from the clinic (in case of the event that the clinic was inaccessible)?

  Yes

  No

• Personal Protective Equipment (PPE) (2 per nurse assigned to campus) is clearly labeled and stored in a secure location.

  Yes

  No

• Campus crisis plan and standard response protocol chart are available and the role of the nurse is understood.

  Yes

  No

• Are the original "gold forms" and a printed version of the current health conditions list easily accessible?

  Yes

  No

• Are health cards and student health information forms able to be locked up (locking file cabinet or clinic door)?

  Yes

  No

• Does the nurse have an updated notebook/written plan for substitutes to follow (using updated template)?

  Yes

  No

• Are parent emergency phone numbers easily accessible?

  Yes

  No

• Is the nurse properly identified as a registered nurse?

  Yes

  No

• Is the nurse using the most up-to-date forms (special procedure forms, staff training forms, accident reports, etc)?

  Yes

  No

AED(s)

• Are school AED(s) accessible to all school personnel during all hours (mounted in recessed cabinet in public area)?

  Yes

  No

• Are AED location signs posted in the school?

  Yes

  No

• Is each AED notebook up-to-date regarding the daily/monthly maintenance checks?

  Yes

  No

• Are the AED pads current (non-expired)?

  Yes

  No

• Are the correct pad expiration dates listed in the AED notebook?

  Yes

  No

• Is there a list of current personnel with valid certification expiration dates on the AED sheet? (minimum 3 per campus)

  Yes

  No

• Has an Emergency Response Team (6 person minimum) been established for the year?

  Yes

  Not Yet

• Has the team participated in an AED drill WITHOUT students present this year?

  Yes

  Not Yet

• Has the team participated in an AED drill WITH students present this year?

  Yes

  Not Yet

Medications

• Are medications* stored out of reach of children in a locked cabinet? (*except for severe allergy medication)

  Yes

  No

• Are emergency diabetic supplies and anaphylaxis medications easily accessible in a secure but unlocked location?

  Yes

  No

• Are they labeled in such as way as to be located quickly by staff?

  Yes

  No

• Are inhalers stored in a manner that would be easily removed and carried during a fire/other emergency?

  Yes

  No

• Are current year "Principal Designees for Medication Administration" and "Medication Signature" forms completed and accessible in the medication book?

  Yes

  No

• Have all personnel administering medications signed off on the Medication Signature sheet?

  Yes

  No

• Is the evaluator able to locate current year completed staff medication training forms for staff administering medications?

  Yes

  No

• Do all medications have a completed and signed Parent/Physician Authorization to Administer Medications form?

  Yes

  No

• Are all prescription medications in their original container and properly labeled with a pharmacy label that matches the Parent/Physician Authorization to Administer Medications form?

  Yes

  No

• Are all OTC meds in their original container and properly labeled with the student's first and last name?

  Yes

  No

• Are medications being signed off as given with the time and initials of administrator on the RISD Med form?

  Yes

  No

• Is an up-to-date medication check-off sheet being utilized?

  Yes: Focus generated

  Yes: Nurse generated

  No check-off sheet

• Run the Medications checklist report for the campus in Focus. Compare this list with the one being used in the medication book.

• Have all medications been entered into Focus?

  All

  Most

  Few

  None

• Are the appropriate Days to be Administered checked (the days the med should be available for use)?

  Yes

  No

• If there have been missed medications or medication errors, has the nurse completed and submitted incident reports to the Director of Health Services?

  Yes

  No

  N/A

Documentation

• Are clinic visits up-to-date in Focus? (entered and in Completed Events section of log)

  Yes, up-to-date through today

  Only 1-3 days behind in log

  4 days or more behind in log

• Has a clinic visit documentation audit been completed for the nurse this semester?

  Yes

  Not Yet

• Run a current Nurse Health Conditions report in Focus (or review a recently printed version of this report).

• Has the nurse entered a comment for each health condition (not just the disease code)?

  Yes

  No

• Have health condition comments been cleaned up since the data transfer from Star Student (previous dates are removed from the comments, etc)?

  Yes

  No

• Run the Medical Alerts report for the campus (Reports menu, but not under District Reports) in Focus.

• Are all medical alerts appropriate? <br>~ there is no hearing/vision related alert info coded as a MEDICAL alert<br>~ alerts are appropriate (think life-threatening/urgent...ex: an alert for ADHD is not appropriate)

  Yes

  No

• Is an EFFECTIVE documentation method in place when the nurse is out of the building?

  Yes

  No

• Are Individualized Healthcare Plans in place for pertinent students?

  Yes

  No

• Have the IHPs, EAPs, and any applicable physician orders been uploaded into Focus for the school year?

  All

  Most

  Few

  None

• Have the IHPs for special education students been uploaded into eSTAR Archive Manager?

  All

  Most

  Few

  None

• Was the auditor able to review an IHP during the visit?

  Yes

  No

• Will a time be arranged to provide the nurse feedback regarding an IHP prior to his/her evaluation?

  Yes

  No

• Describe the quality of the health history and assessment sections.

  Missing (no info)

  Good info, but some key issues not addressed

  Thorough, pertinent information

• Notes:

• Did the nurse identify appropriate nursing diagnosis(es) based on assessment data, and using standardized nursing language?

  Yes

  No

• Did the nurse develop goals for the student/family related to the selected nursing diagnosis(es)?

  Yes

  No

• Did the nurse utilize NOCs appropriate to the selected nursing diagnosis(es)?

  Yes

  No

• Are the NOC indicators appropriate for the student?

  Yes

  No

• Has the nurse completed the initial evaluation of the NOC indicators and calculated the initial overall NOC score?

  Yes

  No

• Are the listed Nursing Interventions (NIC) appropriate for the student?

  Yes

  No

• Are the Nursing Services minutes reflective of the amount of SCHEDULED nursing care the student needs when RISD is providing the care?

  Yes

  No

• Is there a student with a private duty nurse on the campus?

  Yes

  No

• Does the school nurse:

• Have current RISD orders uploaded (not just agency orders)?

  Yes

  No

• Have an IHP for the student (complete with RISD nurse assessment etc)?

  Yes

  No

• Know the child and his/her care well enough to step in and provide care on short notice?

  Yes

  No

Immunizations

• Does the nurse have a process in place to monitor ongoing immunization compliance?

  Yes

  No

• Are there students enrolled at the campus that have a CO or medical exemption (1M or LM)?

  Yes

  No

• Are the original exemption documents filed in the students' CUM folders?

  Yes

  No

Miscellaneous

• Have all initial screenings for Hearing/Vision/AN been completed?

  Yes

  Not Yet

• Have all rechecks been completed?

  Yes

  Not Yet

• Is progress on referrals being documented?

  Yes

  No

• Has student data been entered/updated in the ANTES system?

  Yes

  Not Yet

  NA

• Scoliosis Screening

  Done

  Date Set

  Not Set

  NA

• Growth & Development / HIV classes

  Done

  Date Set

  Not Set

  NA

• Has a Campus Food Allergy Management Team been set up for this year?

  Yes

  No

• Has the Team had at least one meeting this year?

  Yes

  No

• Has a date been set for the meeting?

  Yes

  No

Additional Comments

Clinic Equipment

• Does the clinic have a functioning...

• Oral thermometer

• Temporal or infrared thermometer

• Stethoscope (in addition to ones in emergency bags) (district issued)

• Nebulizer

• Pulse Oximeter

• Large Adult BP cuff (in addition to ones in emergency bags)

• Adult BP cuff (in addition to ones in emergency bags)

• Pedi BP cuff (in addition to ones in emergency bag)

• Automatic BP monitor (optional)

• Wall-mounted stadiometer

• Scale

• Wheelchair

Reference Materials

• Blood-borne Pathogens Manual

• Davis Drug Guide

• Year

  Select 2009 2010 2011 2012 2013 2014 2015 2016 2017

  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017

• Dermatology

• Growth & Development materials

• Medical Dictionary

• Health Care Plans for School Nurses

• Minor Emergencies

• Nursing Diagnoses 2015-2017 (NANDA) book

• Nursing Outcomes Classification (NOC) book

• Redbook

• Year

  Select 2009 2010 2011 2012 2013 2014 2015 2016 2017

  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017

• School Nursing (Selekman)

• Supporting Students w/Special Health Care Needs (purple spiral or 3rd ed.)

• Sports First Aid

• 2016 School Nurse Resource Manual

• School Nurse

  Sign

• Auditor

  Sign