Planning and Preparation

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

Vision and hearing screening.
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.

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

Principal designee for medication.
Designee has been trained, skills check present.

Medication consent
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)

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

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

Bloodborne Pathogen Training for Personnel Without Eduphoria Access
Due October 1


Nursing Practice

Medication is stored per PISD Policy, locked in cabinet

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

Medication administration documentation
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.

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

Health alerts
Evidence required- 108 report AND electronic or paper receipt signed by teachers

Nurse has trained back up personnel in all procedures and has current skills checklists present

AED weekly checklist is current, dated and signed.

current or N/A


Clinic Environment

Clinic is neat, orderly and free of clutter

Supplies are organized, rotated for efficiency, easily accessible

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

Daily Sign in Log for Attendance

All equipment is state/district approved and in working order


Vision screening equipment

Lighted vision cabinet
The state requires all referrals be off of a lighted cabinet

Blood pressure cuffs
Multiple sizes


First Aid Kit
Checked and stocked, easily accessible


Pulse Oximeter

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

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

Audiometer model and style Enter name of unit:

Comments regarding equipment:


Continuing education hours Pasadena ISD staff development
Minimum 26 PISD staff development hours

Continuing Nursing Education Off duty hours
Minimum 10 hours relevant to school nursing

Vision partnership participation
students sent to see to succeed or vouchers, last year all students served

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

Health Promotion
Hosts health fair, immunization clinic or other health related event to benefit students

Copy of current RN licensure, BLS CPR/AED card, current vision and hearing screening certificate

Appearance: scrubs or professional attire with lab coat

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?

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

Additional Remarks

Campus Registered Nurse Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.