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GCISD Clinic Walk Through
GCISD Clinic Walk Through
Amy Howard

GCISD Clinic Walk Through

Clinic Evaluation

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Free GCISD Clinic Walk Through Checklist

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Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location

  • Personnel

Clinic Setup

  • Bulletin Board/Educational Material Available and Visible?

  • Well organized, orderly, free of clutter?

  • Follow up with corrected action will be completed by:

  • Cleaner for cots?

  • Bathroom Key is easily accessible?

  • Follow up with corrected action will be completed by:

Medication Procedure

  • Picture of student on MAR or Medication Bottle?

  • Follow up with corrected action will be completed by:

  • All Medication Permission Forms are signed by the parent?

  • Follow up with corrected action will be completed by:

  • Controlled Substance and OTC medications have physician signature if to be given for longer than 10 days or doses whichever is greater?

  • Follow up with corrected action will be completed by:

  • Administration of Scheduled Medication, and Medication Inventory is documented daily in Skyward?

  • Follow up with corrected action will be completed by:

  • Controlled Substance counted, and documented daily by RN, witnessed weekly?

  • Follow up with corrected action will be completed by:

  • Medication is organized and stored with controlled substance placed in locked cabinet?

  • Follow up with corrected action will be completed by:

  • Pink PRN medication notebook organized by Alpha Tabs?

  • Follow up with corrected action will be completed by:

  • Rx label and Medication Permission Form match?

  • Follow up with corrected action will be completed by:

  • Inhalers accessible, clearly marked, and unlocked during the school day?

  • Follow up with corrected action will be completed by:

Unlicensed Assistive Personnel

  • Principal Designation Form signed for: Medication, UDCA, Cath, TF, Diastat, and VNS. Form is in located in the front of the Teal Daily Medication Notebook.

  • Medication

  • UDCA

  • Cath

  • TF

  • Diastat

  • VNS

  • Follow up with corrected action will be completed by:

  • Skills Checklist are complete for all staff members who have been designated by the principal (initial and return demonstrations documented)?

  • Follow up with corrected action will be completed by:

Diabetes Care

  • UDCA Authorization Form signed by parent?

  • Follow up with corrected action will be completed by:

  • Diabetes Management and Treatment Plan is current, signed by parent and physician?

  • Follow up with corrected action will be completed by:

  • Emergency Kits available for students, or student self carry in the event of lockdown, or evacuation?

  • Follow up with corrected action will be completed by:

Anaphylaxis/Severe Allergies

  • Student Specific Epi Auto-Injectors are accessible, clearly marked, and in unlocked cabinet during the school day?

  • Follow up with corrected action will be completed by:

  • Standing Order Epi Auto Injectors are in Yellow Locker, and Monthly Checks are being Performed?

  • Follow up with corrected action will be completed by:

Special Procedures

  • Orders for special procedures are current, and signed by parent and physician?

  • Follow up with corrected action will be completed by:

IHP/EAP/Critical Alerts

  • Number of Students with Asthma?

  • Number of Students with Diabetes?

  • Number of Students with Severe Anaphylaxis?

  • Number of Students with Seizure Disorder?

  • Number of Students with Daily Procedures? (Cath, Tube Feed...)

  • Skyward has been updated to reflect critical alerts if appropriate?

  • Follow up with corrected action will be completed by:

  • IHPs have been created or updated for identified students?

  • Follow up with corrected action will be completed by:

  • IHPs include evidence of interventions completed and goals being met or in progress (nurses notes in office visits, medication administration notes, on IHP, skills checklist, etc...)?

  • Office Visits

  • On IHP

  • Skills Checklist

  • Medication Administration Record

  • Follow up with corrected action will be completed by:

  • Notification of need to know staff has been done and documented (Teachers, Nutrition, Transportation, 504 Coordinator...)?

  • Teachers

  • Coaches

  • Nutrition

  • Transportation

  • 504 Coordinator

  • Follow up with corrected action will be completed by:

Emergency Preparedness

  • Health Information Sheets are printed and available to be quickly accessed during an emergency?

  • Follow up with corrected action will be completed by:

  • Evacuation plan in place for medications, special procedures, supplies/equipment?

  • Follow up with corrected action will be completed by:

  • Emergency bag is intact, readily accessible?

  • Follow up with corrected action will be completed by:

AED

  • AED Team has been identified?

  • Follow up with corrected action will be completed by:

  • AED Team drills planned or held?

  • AED monthly checks are performed?

  • Follow up with corrected action will be completed by:

Substitute Folder

  • Section 1: Daily Schedule

  • Section 2: General Information (phone list)

  • Section 3: Maps and School Schedule (including special schedule)

  • Section 4: Common Forms (accident/incident, head injury, impairment assessment, jot sheets...)

  • Section 5: Special Needs List (campus list and back up nurse campus list)

  • Section 6: Emergency Plans (IHPs/EAPs)

  • Section 7: AED Plan

  • Section 8: Assessment Guide

Comprehensive School Health Program

  • Flex hours complete?

  • Follow up with corrected action will be completed by:

  • Office Visits are documented daily in Skyward?

  • Follow up with corrected action will be completed by:

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

  • Follow up with corrected action will be completed by:

  • Special Event/Committee involvement?

  • What events or committees?

  • Review of goals.

Immunization

  • Immunization compliance report is up-to-date?

  • Follow up with corrected action will be completed by:

  • Tracking System in place?

Special Senses (Vision/Hearing/Spinal/AN)

  • Self Audit: screening certification up-to-date?

  • Monthly biological calibrations of audiometer documented?

  • Follow up with corrected action will be completed by:

SHARS

  • Monthly SHARS up-to-date?

  • Follow up with corrected action will be completed by:

  • Number of Procedure SHARS?

  • Number of Medication SHARS?

PRS (Pregnancy Related Services) (Secondary Only)

  • Process in place to identify pregnant/parenting students?

  • RN refers for necessary services?

  • RN provides prenatal/parenting education?

  • RN provides regular follow up?

Follow Up

  • Is follow up necessary?

  • RN Signature

  • Director of Health Services

GCISD Clinic Walk Through
Amy Howard

GCISD Clinic Walk Through

Clinic Evaluation

Use this Template
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.

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