School Health Services Clinic Audit

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

Medication Administration FFAC (local)

• Principal designee for medication administration form completed and filed in Medication binder

  Yes

  No

  N/A

• Permission forms from parent/MD completed and filed in Medication binder

  Yes

  No

  N/A

• Medications organized and stored according to CFISD policy

  Yes

  No

  N/A

• Epinephrine auto-injectors stored in unlocked cabinet marked "Emergency Medications"

  Yes

  No

  N/A

• Permission for self-administration of medication completed and filed in Medication binder

  Yes

  No

  N/A

• Administration of medication is documented daily in electronic medical record (EMR)

  Yes

  No

  N/A

Office Visit Documentation

• Office visits are documented daily in EMR<br>

  Yes

  No

  N/A

Immunization Documentation

• Immunization compliance report is up to date (as medically possible)

  Yes

  No

  N/A

• Immunization exemption certificates and MD letters are filed in Exemption binder and documented in EMR

  Yes

  No

  N/A

• Documented parent/guardian notification of immunization requirements

  Yes

  No

  N/A

• Documented notice to campus administration concerning immunization non-compliance

  Yes

  No

  N/A

Screening

• Vision and hearing screening completed 120 days from student enrollment

  Yes

  No

  N/A

• Spinal and Acanthosis Nigricans screening completed by Spring break

  Yes

  No

  N/A

• Screening results documented in EMR

  Yes

  No

  N/A

• Documented monthly biological calibration of audiometer

  Yes

  No

  N/A

• Demonstrated knowledge of community assistance for vision exams

  Yes

  No

  N/A

Clinic Management

• Clinic is orderly and free of clutter

  Yes

  No

  N/A

• Supplies are easily accessible

  Yes

  No

  N/A

• Otoscope, pulse ox., thermometer, and sphygmometer are in working order

  Yes

  No

  N/A

Substitute Notebook

• Organized according to CFISD guidelines found in health services handbook

  Yes

  No

  N/A

• Updated with current campus specific information

  Yes

  No

  N/A

• Current telephone lists with nearest campus RN phone numbers included

  Yes

  No

  N/A

• Current campus Alert & Disability roster included

  Yes

  No

  N/A

Special Services

• Current orders (updated annually) for special procedures in appropriate binder

  Yes

  No

  N/A

• Current IHPs for identified students

  Yes

  No

  N/A

• Documented training for delegated procedures<br>

  Yes

  No

  N/A

• Documented supervision of delegated procedures

  Yes

  No

  N/A

• Principal UDCA delegation form signed and filed in Diabetes binder

  Yes

  No

  N/A

• Documented UDCA training filed in Diabetes binder

  Yes

  No

  N/A

Emergency Preparedness

• Evacuation plan in place

  Yes

  No

  N/A

• Emergency trauma bag properly stocked and easily accessible

  Yes

  No

  N/A

• Rolling cart to evacuate medications is easily accessible

  Yes

  No

  N/A

• AED checklists current (inspected monthly)

  Yes

  No

  N/A

• Documented evacuation training on file for 2 story campuses

  Yes

  No

  N/A

Audit Results

• Is follow up audit necessary?

  Yes

  No

  N/A

• When will follow up audit take place?

  2 weeks

  3 months

  6 months

• Auditor's Signature

  Sign

• Additional Remarks

• Campus Registered Nurse Signature

  Sign