HISD Health and Medical Services Program Evaluation -Rev 2015

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Program and Professional Highlights

• Contributes to professional growth of peers as a mentor or preceptor.

• 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

• Referral to School based clinic partners or mobile health care services

• Dental Projects

  Off

  On

• Project Saving Smiles

• UT School of Dentistry

• Dental Poster Contest

• Vision Partnership(s)

  Off

  On

• Kids vision for life

• UH School of Optometry

• Eye Care for Kids

• Others

  Off

  On

Estimated Program Acuity

• Campus enrollment

• Number of nurses on campus full time

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

• Number of students with an invasive procedure.

• Are any procedures delegated?

  Yes

  No

  N/A

• Number of students with a documented chronic health condition requiring daily management during school hours.

• Number of students with a documented chronic health condition at risk for emergent care during school hours.

• Asthma

• Risk for anaphylaxis.

• Diabetes

• Seizure

• Other

• # of students on daily medication

Medication Procedures

• 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

• A medication administration form is in designated binder, completed for each student and accurately reflects physician orders.

  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

• Principal Medication assignment form is complete and easily accessible

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

• Drug information is included in the medication book.

• 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

• 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

• Yes

  No

  N/A

• Student says his/her name.

  Off

  On

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

  Off

  On

• If other, enter here

Utilizing the nursing process

• Documents subjective data collected from the student/client

  Yes

  No

  N/A

• Assesses and documents objective data

  Yes

  No

  N/A

• Analyses all data and documents in appropriate nursing language utilizing electronic health record

  Yes

  No

  N/A

• Establishes a nursing diagnosis and plan of care

  Yes

  No

  N/A

• Determines and documents nursing intervention

  Yes

  No

  N/A

• Evaluates care with follow up as necessary

  Yes

  No

  N/A

Case Management of Students with Chronic Health Conditions

• Completed search in electronic health record (EHR) 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

• Medical Alert and Conditions screen in EHR 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

• IHP and Emergency Plan developed for each identified 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

Case Management of students with special healthcare needs/ invasive procedures

• Students enrolled who require invasive procedures?

  Yes

  No

  N/A

• If no, skip to last question in this section.

• 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

• 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

• 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

• 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

• If delegated to unlicensed staff, is there evidence of training 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

• 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

• 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

Asthma management

• School nurse shows competence with asthma management? (I.e. Demonstrates understanding of asthma action plan, accurate use of inhaler).

  Yes

  No

  N/A

• Students enrolled with asthma?

  Yes

  No

  N/A

• If no skip to next section.

• # Asthma Action Plans equals # students on conditions report?

  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

• List any challenges, trends that impact return of action plans, steps taken and any plans for follow up.

• 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

Anaphylaxis

• Students enrolled with risk for anaphylaxis?

  Yes

  No

  N/A

• Answer next appropriate questions below and then skip to next section

• #Allergy Action Plans equal # students on conditions report?

  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

• List any challenges, trends that impact return of action plans, steps taken and any plans for follow up.

• School nurse shows evidence of completion of food allergy training (i.e. online, CNE)

  Yes

  No

  N/A

• Follow up corrective action by stated date

  stated date

• Anaphylaxis 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

• Staff-specific training (Level 2) including use of auto-injector 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

• Principal designated staff trained in use of epinephrine

  Yes

  No

  N/A

• Follow corrective action will be taken by

  Select 1 day 10 school days 30 days 60 days

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

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

  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.

  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 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

Diabetes Care

• School nurse shows evidence of completion of diabetes training including intense insulin management (i.e. Online course, CNE offering, experience, attest action form).

  Yes

  No

  N/A

• Follow up will be completed by

  Select stated date

  • stated date

• Utilizes appropriate medication administration form for intense insulin management.

  Yes

  No

  N/A

• Follow up corrective action completed by

  Select 1 day 10 school days 30 days 60 days

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

• Diabetes Management and Treatment Plan is 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

• Diabetes Awareness Training (level 1) completed for designated staff?

  Yes

  No

  N/A

• Staff-specific training (level 2) 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

• Principal designated staff trained in diabetes care.

  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 skills checklist has been completed (initial and return demonstrations documented) (level 3)

  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.

  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 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

Emergency Preparedness

• Emergency care forms are printed and available to be quickly taken 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

• Personal protective equipment (PPE) supply available

  Yes

  No

  N/A

• Follow up corrective action 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 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 procedures current including checklist and unexpired pads and batteries.

  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

• Documents 911 assessment. Retains on campus. Available upon request.

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

• Wears RN insignia as required by nursing licensure.

• Years of experience in HISD

• Licensure renewal date

  as indicated

• Select date

  Date

• Professional attire appropriate for school setting reflecting personal safety and safe delivery of care.

• 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

• 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

• 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

Clinic equipment and procedures

• Clinic environment neat 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.

  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.

  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 books readily accessible

  as indicated

• Health Services Handbook

  Off

  On

• Individualized Health plans

  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 for current school year?

  Yes

  No

  N/A

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

  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

• # students unresolved for vision from previous school year

• # students unresolved for hearing from previous school year?

• # students unresolved for acanthosis from previous school year?

• # students unresolved for spinal screening from previous school year?

• If participated in dental screening program, # of students remaining unresolved for dental followup in current school year ?

• 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

• 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

• Growth and Development education conducted according to health TEKS.

  Yes

  No

  N/A

• Enter TEKS addressed and presentations offered.

• Comments

• Program Specialist, Health and Medical Services

  Sign

• Select date

  Date

• School Nurse

  Sign

• Comments

• Select date

  Date