ROOM SETUP

  • Bulletin Board

  • Will have corrected by:

  • Educational Information available/visible?

  • Will have corrected by:

  • Well Organized?

  • Will have corrected by:

  • Cleaner for cots available/used?

  • Will have corrected by:

  • Adequate supplies available?

  • Will have corrected by:

  • Lunch time schedules posted?

  • Will have corrected by:

  • Voicemails Updated?

  • Will have corrected by:

  • Bathroom key is easily accessible?

  • Will have corrected by:

Substitute Information

  • Location:

  • Substitute Information is:
    Organized?
    Clear?
    Easy to Understand?

  • Will have corrected by:

  • Complete with list of "Alerts"?

  • Will have corrected by:

Medication Storage and Administration

  • Medication secured in a locked cabinet?

  • Will have corrected by:

  • Keys to medication secure? Duplicate set kept?

  • Will have corrected by:

  • Controlled substances count by RN documented?

  • Will have corrected by:

  • Rx label and Medication Authorization match?

  • Will have corrected by:

  • Any medications left in the clinic from last school year?

  • Will have corrected by:

  • Any expired medications on campus?

  • Will have corrected by:

  • Classroom medications secure and monitored weekly by RN?

  • Will have corrected by:

  • Any missing medications?

  • Protocol followed for missing medication?

  • Will have corrected by:

  • Epi-Pens accessible and clearly marked?

  • Will have corrected by:

Case Management SHARS

  • Number of medication SHARS?

  • Number of procedure SHARS?

  • Monthly SHARS up to date and on Monthly Report by 5th working day of the month?

  • Will have corrected by:

  • Copies of SHARS filed?

  • Will have corrected by:

IHCP/Orders

  • Number of Asthma students (from Alerts List)?

  • EAP's complete with MD orders when appropriate?

  • Will have corrected by:

  • Number of Diabetic Students?

  • Diabetic IHCP's complete with MD orders and signatures complete?

  • Will have corrected by:

  • Number of Seizure students?

  • Seizure IHCP's complete with MD orders and signatures complete?

  • Will have corrected by:

  • Number of students with Food Allergies/Severe Allergies/Anaphylaxis?

  • Allergy/Anaphylaxis IHCP complete with orders and signatures complete?

  • Will have corrected by:

  • Epinephrine Delivery devices clearly marked in unlocked cabinet?

  • Will have corrected by:

  • Epi-Trainers REMOVED, clearly marked, and in another location?

  • Will have corrected by:

  • PEEP's (Personal Emergency Evacuation Plan) completed and signed?

  • Will have corrected by:

  • Number of medical procedures, including but not limited to: Tube feedings Catheterizations Routine nebulizer treatments Etc

  • Medical procedure IHCP complete with MD orders and signature complete?

  • Will have corrected by:

  • Attend meetings as needed? (ARD's, 504, etc)

  • Will have corrected by:

Documentation of Competency for Staff

  • CPR Certified Staff-(at least 2 per campus)

  • Will have corrected by:

  • UDCA (Unlicensed Diabetic Care Assistant)
    Full Time RN on campus=1 per campus minimum

  • Will have corrected by:

  • Medication Administration:2 per Campus

  • Will have completed by:

  • Special Procedures: (if needed)

  • Will have completed by:

  • All training forms are complete and have signatures for: UDCA's, Medication Adminstration Staff Members, and Special Procedures Staff.

  • Will have corrected by:

Medical Alert/Emergency Contact Information

  • Medical Alert list printed and acknowledged?

  • Will have corrected by:

  • New medical alerts entered and confirmed in Nurse Aid?

  • Will have corrected by:

  • Medical Conditions Information entered into Nurse Aid?

  • Will be corrected by:

Daily Log Documentation (review/Audit Nurse Aid)-Random**

  • Reviewer A Score (Total of Columns A-P)

  • Reviewer B Score (Total of columns A-P)

  • Reviewer C Score

  • Final Score (Total of Columns A-P divided by Total # of columns-15)

Immunizations

  • Effective tracking system in place to monitor compliance of all students?

  • Will have corrected by:

  • Immunizations entered into E-school in a timely matter (2 weeks for new students)

  • Will have corrected by:

  • Process in place to deal with non-compliance of immunizations?

  • Will have corrected by:

Pregnant and Parenting students (Secondary)

  • Process in place to identify pregnant/parenting students (Notification of process to faculty/staff)

  • Will have corrected by:

  • RN refers students for necessary services

  • Will have corrected by:

  • RN provides prenatal/parenting education to students?

  • Will have corrected by:

  • RN provides regular follow-up with pregnant students

  • Will have corrected by:

  • RN collaborates with Homebound services?

  • Will have corrected by:

  • Completed case files are sent to PRS Coordinator after student returns to school or at the end of the school year?

  • Will have corrected by:

Campus Projects (Sports Physicals, Back to school, Presentations)

  • List:

Vision and Hearing

  • Copies of referrals available?

  • Will have corrected by:

  • Number of students NOT screened for Vision/Hearing, including new students?

  • Will have corrected by:

  • Number of Vision referrals in process (P)?

  • Number of Vision referrals complete?

  • Number of Hearing referrals in Process (P)?

  • Number of Hearing referrals complete (C)?

  • Nurse Aid data entry completed by April 1st?

  • Will have corrected by:

  • Monthly biological checks of audiometer documented and stored in audiometer ?

  • Will have corrected by:

  • Number of Nurse Aid data entries (for Vision & Hearing) in progress?

Spinal Screening

  • Number of 2nd semester Spinal screenings in progress?

  • 2nd Semester Spinal screening completed by the end of March?

  • Will have completed by?

  • Number of 2nd Semester Spinal referrals in progress?

  • Are second semester referrals in progress (P) or completed by the end of March?

  • Nurse Aid data entry for Spinal Screening completed by April 1st?

  • Will have corrected by:

  • Number of Nurse Aid data entries (for Spinal screenings) in Progress?

Acanthosis Nigricans Screening

  • 1st semester AN screenings completed by end of December?

  • Will have corrected by:

  • Number of 1st Semester AN screenings in progress?

  • 1st Semester AN Referrals* in Progress (P) or Completed (C) by end of December?

  • Will have corrected by:

  • 2nd Semester AN screenings done by the end of February?

  • Will have completed by:

  • Number of 2nd Semester AN screenings in Progress?

  • 2nd Semester AN Referrals* in Progress (P) or completed (C) by the end of February?

  • Will have corrected by:

  • ANTES Data* entry in progress (P) or completed (C) by April 1st?

  • Will have corrected by:

Risk Management

  • Accident and Incident reports completed per HEBISD protocol?

  • Will have completed by:

  • RN follows communicable disease protocols (% of absenteeism, TCHD reportable diseases, exclusion criteria)?

  • Will have corrected by:

  • Campus Concerns/Issues:

NOTES

  • Signature of RN/LVN:

  • Signature of Evaluator:

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