Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Personnel
Medication Procedures and Medication Binder
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FRONT OF BINDER: Current clinic standing orders
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Principal designation forms for medication administration are completed.
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Follow up with corrective action will be completed by:
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DIABETES
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DMTP current, signed by parent and physician, with student photo attached.
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Follow up with corrective action will be completed by:
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EAPs (extracurricular, teacher, specials) completed for each student, as needed.
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Follow up with corrective action will be completed by:
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UDCA authorization (present on signed DMTP or UDCA Authorization form).
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Follow up with corrective action will be completed by:
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EMS--extra copies in labeled envelope for EMS personnel.
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Follow up with corrective action will be completed by:
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Transportation plan, if bus riders
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SEIZURES
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Seizure action plans, parent questionnaires, and/or information about seizure condition is present and current.
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Diastat orders are complete and emergency action plan in place with need-to-know staff.
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Transportation plan completed, copy given to bus driver and to Transportation Supervisor, if bus riders.
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SCHEDULED MEDICATIONS AND PROCEDURES<br>All medication requests are signed by the parent. <br>OTC medications have a physician order if going to be kept longer than 5 days.
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Follow up with corrective action will be completed by:
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Two (2) unique patient identifiers are present on each medication permission form.
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Select all that apply:
- DOB
- Student ID
- Photo
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SECTION 1: CAMPUS CONTACT INFORMATION<br>(Substitute information form completed)
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Follow up with corrective action will be completed by:
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Current telephone lists with campus RN phone numbers included.
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Follow up with corrective action will be completed by:
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Administration of medication is documented daily in Skyward (WISD Electronic Medical Record-EMR)
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Follow up with corrective action will be completed by:
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Medication organized and stored with controlled substances placed in double locked cabinet.
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Follow up with corrective action will be completed by:
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Permission for Self-Carry/Administration of medication competed and filed in Medication Binder.
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Follow up with corrective action will be completed by:
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Scheduled Medications:
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Physician orders current and written permission from parent has been completed on order form or medication permission form.
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Follow up with corrective action will be completed by:
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Procedure flowsheets, if needed.
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Scheduled Procedures:
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Physician orders current and written permission from parent has been completed on order form or medication permission form.
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Follow up with corrective action will be completed by:
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Procedure flowsheets, if needed.
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SEVERE ALLERGY/EPIPEN
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Anaphylaxis action plans (AAP) or medication permission forms completed and signed by parent/physician.
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Follow up with corrective action will be completed by:
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Student photo added to AAPs/Medication Permission forms
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Follow up with corrective action will be completed by:
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BACK OF BINDER: Discontinued medications/procedures for current school year only. Discontinued forms may also be filed in student health file.
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PRN MEDICATIONS<br>PRN meds organized by alpha tabs.
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Follow up with corrective action will be completed by:
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All medication requests are signed by the parent. All OTC medications have a physician order if kept longer than 5 days
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Two (2) unique patient identifiers are present on each medication permission form.
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Select all that apply:
- DOB
- Student ID
- Photo
Unlicensed Assistive Personnel
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Medication skills checklists are complete for all staff members who have been assigned by the Principal to administer medications (UAPs, field trips, coaches, extra-curricular).
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Follow up with corrective action will be completed by:
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Office Staff protocols are located where UAPs can readily access them.
Diabetes Care
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UDCA skills checklists have been completed.
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Return demonstration/ review of UDCA skills will be performed and documented:
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Has a physical assessment been completed and documented in Skyward for students with diabetes?
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Follow up with corrective action will be completed by:
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Emergency kits available for students with diabetes, or students self-carry, in the event of a lockdown or evacuation.
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Follow up with corrected action will be completed by:
Severe Allery/Anaphylaxis
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Level 2 training has been completed along with epinephrine auto-injector and/or medication skills training checklist.
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Follow up with corrective action will be completed by:
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Epinephrine auto-injectors are kept in an unlocked cabinet during the school day.
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Follow up with corrective action will be completed by:
- 1 day
- 10 school days
- 30 days
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Epinephrine auto-injectors are clearly labeled to be rapidly identifiable for emergency use.
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Follow up with corrective action will be completed by:
Special Procedures
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Orders for special procedure(s) are current, signed by parent and physician.
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Follow up with corrected action will be completed by:
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Has a physical assessment been completed and documented in Skyward?
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Follow up with corrected action will be completed by:
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Special procedure skills checklists are completed for any staff member who assists with special procedures.
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Training and competency for any UAP performing a skilled procedure will be assured through initial training and a minimum of three return demonstrations prior to independent performance.
Heath Conditions and Individual Health Plans (IHPs)
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Skyward alert information has been updated/added, critical alert box checked if appropriate.
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Follow up with corrective action will be completed by:
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Has a physical assessment been completed and documented in Skyward for students with health plans, significant medical needs, or cared for routinely.
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IHPs have been created or updated for identified students.
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Follow up with corrected action will be completed by:
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IHPs include evidence of interventions completed and goals being met or in progress (notes in office visit, medication administration notes, on IHP, skills checklists, etc.).
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Follow up with corrected action will be completed by:
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Notification of need-to-know staff has been done and documented (teachers, 504 coordinator, coaches, extra- curricular sponsors, child nutrition manager).
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Follow up with corrective action will be completed by:
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IHPs have been uploaded and or created in Skyward.
Emergency Preparedness
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Emergency care consent forms are printed and available to be quickly accessed during an emergency.
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Follow up with corrected action will be completed by:
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AED/MERT has been identified.
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Follow up with corrected action will be completed by:
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AED/MERT DRILLS/TRAINING:<br>First semester drill completed and documented. Date:
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Follow up with corrective action will be completed by:
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AED/MERT DRILLS/TRAINING:<br>Second semester drill completed/scheduled. Date:
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Follow up with corrective action will be completed by:
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Emergency bag is stocked, contents are unexpired, and readily accessible.
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Follow up with corrected action will be completed by:
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Evacuation plan in place for medications, special procedures and diabetes supplies/equipment.
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Follow up with corrected action will be completed by:
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Evacuation of clinic emergency supplies has been practiced with at least one fire/evacuation drill.
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Plan for practice with next scheduled fire/evacuation drill, with follow up in:
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AED monthly and annual checks are performed.
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Follow up with corrective action will be completed by:
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Documented evacuation training on file for 2 story campuses
Substitutes and Sub RN Binder
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SECTION 1: CAMPUS CONTACT INFORMATION<br>(Substitute information form completed)
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Follow up with corrective action will be completed by:
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Current telephone lists with campus RN phone numbers included.
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SECTION 2: EMERGENCY AND EVACUATION
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School map with AED locations marked.
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Copy of campus Emergency Operations Plan (EOP)
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Copy of AED/MERT Response Plan
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SECTION 3: HEALTH CONDITIONS (Skyward report divided by grades, special care lists).
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SECTION 4: PROCEDURES<br>Information about each procedure; equipment and supplies locations; equipment manuals/where to access; diabetes emergency kit locations.
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Follow up with corrective action will be completed by:
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SECTION 5: ALPHA ROSTERS
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SECTION 6: CLASS BELL SCHEDULE<br>(include teacher phone list if not located on desk).
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SECTION 7: FORMS<br>(extra copies of pertinent forms for subs and UAPs.)
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RN Guidelines reference visible and readily accessible.
Comprehensive School Health Program
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Professional development hours completed with content relevant to school nursing.
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Follow up with corrective action will be completed by:
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Office Visits are documented daily in Skyward.
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Follow up with corrective action will be completed by:
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Immunization compliance report is up to date.
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Documentation of parent contact for getting students up to date.
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Follow up with corrective action will be completed by:
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Self-audit of Hearing, Vision, and Spinal State report has been completed and corrections to data entry have been made.
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Follow up with corrective action will be completed by:
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Documented monthly biological calibration of audiometer
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Follow up with corrective action will be completed by:
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AN screening is completed and entered into RFES.
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Follow up with corrective action will be completed by:
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Clinic is orderly and free of clutter.
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Otoscope, pulse ox, thermometer, and sphygmomanometer are in working order.
Follow Up
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Is follow up necessary?
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Follow up date:
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Select date
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Supervising RN Signature
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Campus RN Signature
Signatures
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Coordinator of Health Services
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School Nurse
