PISD HEALTH SERVICES CLINIC VISIT

• Document No.

• Clinic visit

• Campus Nurse Name

• Conducted on

  Date

• Prepared by

• Name of Campus
  Address

• Personnel

Planning and Preparation

• Immunization status of campus.<br>Plan to have Zero delinquent student immunization records on the last Friday of October, state snapshot date.<br>Printed report, dated last Friday present with zero delinquent records.

  Yes

  No

  N/A

• Vision and hearing screening.<br>Schedule of screening indicating all vision and hearing of required grades, Early childhood, Pre-k, 1st, 3rd, 5th and 7th grade students will be completed by winter break, last school day of December.

  Yes

  No

  N/A

• AED drill plan with one date scheduled first semester, one date scheduled second semester.

  Yes

  No

  N/A

• Principal designee for medication.<br>Designee has been trained, skills check present.

  Yes

  No

  N/A

• Medication consent<br>Randomly check at least 5 medications, ensure label matches consent form for name of drug, dose. If emergency medication, ensure medication is not expired (epinephrine, inhaler, diastat)

  Yes

  No

  N/A

• Crisis team assembled, minimum of 3 CPR/AED trained staff members, copy of certification present.

  Yes

  No

  N/A

• Substitute Nurse binder<br>Sub binder is current for current school year. Binder contains campus specific information, daily scheduled events report, location of keys.<br><br>

  Yes

  No

  N/A

• Bloodborne Pathogen Training for Personnel Without Eduphoria Access <br>Due October 1

  Yes

  No

  N/A

• Comments:

Nursing Practice

• Medication is stored per PISD Policy, locked in cabinet

  Yes

  No

  N/A

• Medication administration identification process<br>Nurse verifies correct student with at least 2 identifiers:<br>Picture of student on med form/med<br>Student states name<br>Student is wearing identification badge<br>Student states name of medication

  Yes

  No

  N/A

• Medication administration documentation<br>Randomly check at least 5 entries in electronic health record for correct dose and time. 30 minutes on either side of scheduled time is acceptable. A no-show is unacceptable. It is responsibility of the nurse to ensure all doses are dispensed. Student refusal must be documented and the parent must be contacted immediately.

  Yes

  No

  N/A

• Documentation<br>Thorough and appropriate documentation follows nursing standards. Minimum of 3 records should be randomly checked, required elements include chief complaint, Assessment, intervention and RAD.

  Yes

  No

  N/A

• Health alerts<br>Evidence required- 108 report AND electronic or paper receipt signed by teachers

  Yes

  No

  N/A

• Skills<br>Nurse has trained back up personnel in all procedures and has current skills checklists present

  Yes

  No

  N/A

• Checklists<br>AED weekly checklist is current, dated and signed.

  Yes

  No

  N/A

• SHARS BILLING<br>current or N/A

  Yes

  No

  N/A

• Comments:

Clinic Environment

• Clinic is neat, orderly and free of clutter

  Yes

  No

  N/A

• Supplies<br>Supplies are organized, rotated for efficiency, easily accessible

  Yes

  No

  N/A

• First Aid supplies<br>No expired supplies, verify by checking at least 3 bottles for expiration dates<br>Only supplies on PISD approved list are found in school clinics.

  Yes

  No

  N/A

• Daily Sign in Log for Attendance

  Yes

  No

  N/A

• Equipment<br>All equipment is state/district approved and in working order<br>

  Yes

  No

  N/A

• Thermometer<br>

  Yes

  No

  N/A

• Vision screening equipment

  Yes

  No

  N/A

• Lighted vision cabinet<br> The state requires all referrals be off of a lighted cabinet

  Yes

  No

  N/A

• Blood pressure cuffs <br>Multiple sizes

  Yes

  No

  N/A

• Stethescope

  Yes

  No

  N/A

• First Aid Kit<br>Checked and stocked, easily accessible

  Yes

  No

  N/A

• Otoscope

  Yes

  No

  N/A

• Pulse Oximeter

  Yes

  No

  N/A

• Audiometer<br>Must meet minimum standards set by state<br>Hz must include 250, 500, 1,000, 2,000, 4,000 & 6,000<br>dB must include 20-70<br>Unit may include more Hz or dB, but no less

  Yes

  No

  N/A

• Monthly biological calibration present<br>Sheet showing testing of unit on 1 person per month, every month,

  Yes

  No

  N/A

• Audiometer model and style Enter name of unit:

• Comments regarding equipment:

Professionalism

• Continuing education hours Pasadena ISD staff development <br>Minimum 26 PISD staff development hours

  Yes

  No

  N/A

• Continuing Nursing Education Off duty hours<br>Minimum 10 hours relevant to school nursing

  0-10 hours

  11-13 hours

  14-20 hours

  21 or more hours

• Vision partnership participation<br>students sent to see to succeed or vouchers, last year all students served

  Yes

  No

  N/A

• Leadership quality<br>Evidence- credentials of advanced practice<br> District Lead Nurse<br> New nurse mentor<br> Student Nurse preceptor for schools of nursing

  Yes

  No

  N/A

• Health Promotion<br>Hosts health fair, immunization clinic or other health related event to benefit students

  Yes

  No

  N/A

• Credentials<br>Copy of current RN licensure, BLS CPR/AED card, current vision and hearing screening certificate

  Yes

  No

  N/A

• Appearance: scrubs or professional attire with lab coat

  Yes

  No

  N/A

Self eEvaluation of Skill Competency

• Female catheterization

• Male catheterization

• G-tube feeding via gravity

• G-tube feeding via pump

• Tracheostomy care, changing ties, changing Trach tube

• Tracheostomy suctioning

• Seizure care Rectal gel

• Seizure care VNS

• Seizure care intranasal

• Care of diabetic student

• Carb counting

• Insulin calculation based on correction factor

Visit results

• Is follow up visit necessary?

  Yes

  No

  N/A

• If yes, follow up visit will occur in 1 week

• If yes, follow up visit will occur in 2 weeks

• If yes, follow up visit will occur in 1 month

• Auditor's Signature

  Sign

• Additional Remarks

• Campus Registered Nurse Signature

  Sign