HEBISD Health Services Checklist

ROOM SETUP

• Bulletin Board

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

• Educational Information available/visible?

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

• Well Organized?

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

• Cleaner for cots available/used?

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

• Adequate supplies available?

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

• Lunch time schedules posted?

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

• Voicemails Updated?

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

• Bathroom key is easily accessible?

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

Substitute Information

• Location:

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

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

• Complete with list of "Alerts"?

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

Medication Storage and Administration

• Medication secured in a locked cabinet?

  Yes

  No

  N/A

• Will have corrected by:

  Select 5 Work Days-1 Week 10 Work Days-2 Weeks 1 Month

  • 5 Work Days-1 Week
  • 10 Work Days-2 Weeks
  • 1 Month

• Keys to medication secure? Duplicate set kept?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Controlled substances count by RN documented?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Rx label and Medication Authorization match?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Any expired medications on campus?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Classroom medications secure and monitored weekly by RN?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Any missing medications?

  Yes

  No

  N/A

• Protocol followed for missing medication?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Epi-Pens accessible and clearly marked?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Copies of SHARS filed?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

IHCP/Orders

• Number of Asthma students (from Alerts List)?

• EAP's complete with MD orders when appropriate?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Number of Diabetic Students?

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Number of Seizure students?

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Epinephrine Delivery devices clearly marked in unlocked cabinet?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• 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?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

Documentation of Competency for Staff

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Medication Administration:2 per Campus

  Yes

  No

  N/A

• Will have completed by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Special Procedures: (if needed)

  Yes

  No

  N/A

• Will have completed by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

Medical Alert/Emergency Contact Information

• Medical Alert list printed and acknowledged?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• New medical alerts entered and confirmed in Nurse Aid?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Medical Conditions Information entered into Nurse Aid?

  Yes

  No

  N/A

• Will be corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

Pregnant and Parenting students (Secondary)

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• RN refers students for necessary services

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• RN provides prenatal/parenting education to students?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• RN provides regular follow-up with pregnant students

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• RN collaborates with Homebound services?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

• List:

Vision and Hearing

• Copies of referrals available?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• 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?

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• 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?

  Yes

  No

  N/A

• Will have completed by?

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Number of 2nd Semester Spinal referrals in progress?

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

Acanthosis Nigricans Screening

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Number of 1st Semester AN screenings in progress?

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have completed by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Number of 2nd Semester AN screenings in Progress?

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

Risk Management

• Accident and Incident reports completed per HEBISD protocol?

  Yes

  No

  N/A

• Will have completed by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

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

  Yes

  No

  N/A

• Will have corrected by:

  5 Work Days-1 Week

  10 Work Days-2 Weeks

  1 Month

• Campus Concerns/Issues:

NOTES

• Signature of RN/LVN:

  Sign

• Signature of Evaluator:

  Sign