HISD Health and Medical Services Program Evaluation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Program Highlights

• Immunization banner received in previous school year for 95-100% compliance

• Special program /nurse recognitions

• Special event/committee involvement.

• Participates in opportunities provided by community partners

  as indicated

• Dental Projects

  Off

  On

• Project Saving Smiles

  Off

  On

• UT School of Dentistry

  Off

  On

• Vision Partnership(s)

  Off

  On

• Kids vision for life

  Off

  On

• UH School of Optometry

  Off

  On

• Immunization outreach

  Off

  On

• Referral to School based or mobile health care services

  Off

  On

• Others

  Off

  On

Estimated Program Acuity

• Number of students with an invasive procedure.

• Number of students with a documented chronic health condition requiring daily management during school hours (note: reflected in #IHP, includes meds)

• Number of students with a documented chronic health condition at risk for emergent care during school hours.(note: this number also reflected by # IHP but likely to be less than number above)

• Asthma

• Risk for anaphylaxis.

• Diabetes

• Seizure

• Other

• Estimated % of day spent on students with chronic or invasive procedures

• Number of nurses on campus full time

Medication Procedures

• There are at least 2 ways safe administration is addressed.

  Yes

  No

  N/A

• Follow up corrective action will be completed by

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Photo ID

  Off

  On

• Student says his/her name.

  Off

  On

• Student says name of medication and/or color of pill.

  Off

  On

• If other, enter here

• Medication label matches administration form and orders. This includes supplements/formula. (Note :medication error form required if indicated.)

  Yes

  No

  N/A

• Follow up corrective action will be completed by

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Medication error form needed?

  Select Yes No Not Applicable

  • Yes
  • No
  • Not Applicable

• Medication requests signed by the parent and physician for each medication on hand.

  Yes

  No

  N/A

• Follow up corrective action will be completed by

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Self-carry medication administration orders are complete for each designated student.

  Yes

  No

  N/A

• Follow up corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Completed SHARS training.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Principal Medication Designation form is complete and easily accessible

• Medication skills checklists complete for all designees (initial and return demonstrations documented).

• Drug information is included in the medication book.

Case Management of Students with Chronic Health Conditions

• IHP and Emergency Plan developed for each student.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Medical Alert and Conditions screen in Chancery updated for all identified students.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Training conducted and documented for use of emergency medication (I.e Diastat, asthma rescue meds, auto injector).

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Completed search in Chancery for students with medical alert/condition

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

Case Management of students with special healthcare needs/ invasive procedures

• Students enrolled who require invasive procedures

  Yes

  No

  N/A

• Skip to last question in this section

  1 day

  10 school days

  30 days

  60 days

• IHP completed and on file for each student.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Emergency plan on file for each student including evacuation procedures.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Orders for special procedure(s) are current, signed by parent and physician.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Treatment consent form completed for each student including parent and physician signature.<br><br><br><br><br><br><br>

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Training conducted with Back-up Nurse.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Name of back up school

• Office and designated staff informed of how and when to activate back up procedures in absence of nurse.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Itinerant nurse request form available and easy to access.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Knowledgeable of whether or not there are procedures at designated back-up school.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

Anaphylaxis

• Students in this category?

  Select Yes No Not Applicable

  • Yes
  • No
  • Not Applicable

• Epinephrine auto injectors kept in an accessible cabinet during the school day.

  Yes

  No

  N/A

• Emergency plan on file for each student including transport of meds in case of evacuation

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• IHP completed and on file for each student, updated for current school year including progress toward goal (s).

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Food Allergy Awareness (Level 1) training completed and documented.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Food allergy level 2 if training including avoidance of allergen and emergency plan

  Yes

  No

  N/A

• Follow up with corrective action by

  1 day

  10 school days

  30 days

  60 days

• Level 3 training to specific staff including administration of epinephrine

  Yes

  No

  N/A

Diabetes Care

• Students in this category?

  Select Yes No Not Applicable

  • Yes
  • No
  • Not Applicable

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

  Yes

  No

  N/A

• Follow up with corrective action by

  1 day

  10 school days

  30 days

  60 days

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Emergency plan on file for each student including procedures in case of evacuation.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• IHP completed and on file for each student, updated for current school year with in evidence of evaluation of progress

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Level I Staff-specific training completed and documented including emergency plan

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• UDCA Principal Designation Form signed

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Level II UDCA skills checklist completed (initial and return demonstrations documented).

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

Emergency Preparedness

• Emergency care forms are printed and available to be quickly retrieved during an evacuation.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

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

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Emergency bag is intact, readily accessible.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Crisis Team has been identified with at least 2 persons trained in CPR.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• AED equipment current including unexpired pads and batteries as evidenced by checklist for each AED.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Location of AED

  as indicated

• Location

AED

• Wall mounted

• Completes 911 report and follow up as needed. (Note:Retain on campus).

Substitutes

• Medication administration binder available.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Current student health condition information is readily available.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Emergency procedures and contacts for campus.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Process for documentation clearly defined.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Location of special procedures, emergency supplies, diabetes supplies clearly labeled.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

Professional Accountabilty

• Years of experience in HISD

• Licensure renewal date

  as indicated

• Select date

  Date

• Continuing nursing education hours current.

• Vision/hearing re certification due before December.

• Knowledgeable of department goals.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  1 day

  10 school days

  30 days

  60 days

• Established individual goals for current school year.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Completed ANTES training

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Self-assessment of skill level for invasive procedures

  as indicated

• Female cath

• Male cath

• G tube/button feeding

• Trach suctioning

• Vent care

• Seizure management using Diastat

• Seizure management using VNS

• Anaphylaxis management using auto injector

• Diabetes management

Clinic equipment and procedures

• Clinic environment free of clutter with student appeal and easy access to supplies and materials.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Audiometer annual calibration current

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Audiometer biological calibration current as evidenced by biological calibration documentation

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Serial number

Audiometer

• Enter name of model

• Enter serial #

• Audiometer properly labeled.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Age-appropriate vision screening tools as evidenced by required charts - no copies, no charts with serifs

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Utilizes Chancery and HEALTH HMS reports to document clinic activities.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Reference materials accessible

  such as

• Access to HMS website

  Off

  On

• Individualized Health plans

  Off

  On

• Health Services Handbook

  Off

  On

• Guidelines for Care of Student With Specialized Procedures

  Off

  On

Communicable Disease Surveillance

• Student documentation reflects appropriate assessment of communicable disease risk.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Utilizes influenza-like illness electronic submission as appropriate.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

Comprehensive School Health Program

• Greater than 90% of students compliant for immunizations based on review of Chancery report and RN feedback.

• Process in place to monitor immunization compliance

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Screening programs complete

• Visual inspection of Hearing, Vision, and Spinal State report/s/planning is correct/complete /practical.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Vision screening follow up percentage

  Select greater than 90% less than 50%

  • greater than 90%
  • less than 50%

• Hearing screening follow up percentage

  Select greater than 90% less than 50%

  • greater than 90%
  • less than 50%

• Spinal screening follow up percentage

  Select greater than 90% less than 50%

  • greater than 90%
  • less than 50%

• Acanthosis screening follow up percentage

  Select greater than 90% less than 50%

  • greater than 90%
  • less than 50%

• Process in place to monitor screening referral and followup.

  Yes

  No

  N/A

• Follow up with corrected action will be completed by:

  Select 1 day 10 school days 30 days 60 days

  • 1 day
  • 10 school days
  • 30 days
  • 60 days

• Growth and Development education conducted according to health TEKS.

  Yes

  No

  N/A

• Enter TEKS addressed and presentations offered.

• Participates in student assessment and academic placement

  as indicated below

• Utilizes Easy IEP

  Off

  On

• Collects and analyzes health information

  Off

  On

• Attends ARD, presenting pertinent health information

  Off

  On

• Participates in 504 process, presenting pertinent health information

  Off

  On

• Comments

• Nurse Specialist, Health and Medical Services

  Sign

• Select date

  Date

• School Nurse

  Sign

• Comments

• Select date

  Date