School Health Services Program Evaluation

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

Comprehensive School Health Program

• School health office orderly and free of clutter.

• Equipment (audiometer, otoscope, scales, pulse ox, sphygmometer, thermometer, phone, computer) in working order

• Gloves are readily accessible in clinic.

  Yes

  No

  N/A

• Visual inspection of Immunization Out of Compliance Report. Are all students compliant or in progress (notes of parent contact are present for students being considered for exclusion)?

  Yes

  No

  N/A

• Conscientious and medical exemptions are current and accurately documented in Skyward. Original form kept in file.

  Yes

  No

  N/A

• Visual inspection of Vision report. Is it correct/complete?

  Yes

  No

  N/A

• Visual inspection of Hearing report. Is it correct/complete?

  Yes

  No

  N/A

• Visual inspection of Spinal State report. Is it correct/complete?

  Yes

  No

  N/A

• Visual inspection of AN report. Is it correct/complete in RFES?

  Yes

  No

  N/A

• Transportation forms are complete if bus rider for students with diabetes, seizures, or other significant health condition. Copy given to bus driver and transportation coordinator.

  Yes

  No

  N/A

• Audiometer monthly biological check offs done.

• Clinic stats reported every month.

• Records are bundled for shredding. Bundled records are shredded in a timely fashion (no excessive amounts of records overdue for shredding are present on campus).

  Yes

  No

  N/A

• Sharps container is securely stored and safely accessible when needed.

  Yes

  No

  N/A

Health Conditions and Individual Health Plans

• Student health history information has been reviewed and entered in Skyward. Skyward has been updated to reflect critical alert if appropriate.

  Yes

  No

  N/A

• Notification of need to know persons has been documented (food service, teachers, 504 coordinator, PE/athletics). Including Emergency Action Plans (EAPs)

  Yes

  No

  N/A

• Has a physical assessment been completed and documented in Skyward?

  Yes

  No

  N/A

• IHPs have been created or updated for identified students.

  Yes

  No

  N/A

• IHPs include evidence of outcomes progress and goals being met (either in office visit or on IHP).

  Yes

  No

  N/A

• Students requiring IHP have been referred for 504 or Sped.

  Yes

  No

  N/A

• Documentation of Special Procedures is through Office Visit- ZSN code is used. *Medicaid reimbursement*

  Yes

  No

  N/A

Medication and Special Procedures. FFAC (legal and local)

• All medication requests are signed by the parent (and if applicable) physician.

  Yes

  No

  N/A

• Are there 2 unique patient identifiers?

  Yes

  No

  N/A

• Select all that apply

  Select medication bottle picture medication form picture Date of Birth Health concerns list

  • medication bottle picture
  • medication form picture
  • Date of Birth
  • Health concerns list

• Drug information is included in the medication book.

• Orders for special procedure(s) are current, signed by parent and physician.

  Yes

  No

  N/A

• Current clinic standing orders are visible in the front of the medication binder.

  Yes

  No

  N/A

• Monthly check offs of standing order medications is complete.

  Yes

  No

  N/A

• Medication Opt out list is present in the medication cabinet or sub binder.

  Yes

  No

  N/A

• Two sets of keys for medication cabinets. Second set of keys are retained at campus at all times.

• Medication keys and medication cabinets are secured at at the time of the audit (visual inspection).

  Yes

  No

  N/A

• Are controlled medications properly secured in a double locked cabinet?

  Yes

  No

  N/A

Inventory of Controlled Medications

• Has an inventory sheet been implemented and performed weekly (preferred) or biweekly (minimum) for each controlled medication on file in the clinic. Inventory reconciliation documents should be kept in the medication binder.

  Yes

  No

  N/A

• Perform inventory review on all controlled medications.

  Yes

  No

  N/A

Unlicensed Assistive Personnel

• Principal Medication Designation form is complete and easily accessible

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Special procedure skills checklists are complete for all designees (initial and return demonstrations) documented.

  Yes

  No

  N/A

Anaphylaxis

• Level 1 training is completed and documented

  Yes

  No

  N/A

• Level 2 training has been completed along with training checklist (initial and return demonstrations documented)

  Yes

  No

  N/A

• Epinephrine auto-injectors are clearly labeled to allow for rapid identification.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Cafeteria manager/assistant student nutrition director has been provided food allergy/special diet requests.

  Yes

  No

  N/A

Diabetes Care

• Total number of students with diabetes.

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 0

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 0

• Total number of students with diabetes that are self-care (do not routinely come to clinic)

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 0

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 0

• Diabetes Management and Treatment Plan is current, signed by parent and physician.

  Yes

  No

  N/A

• UDCA authorization present in DMTP or on UDCA authorization form.

  Yes

  No

  N/A

• UDCA Principal Designation Form is signed

  Yes

  No

  N/A

• UDCA skills checklist has been completed (initial and return demonstrations documented).

  Yes

  No

  N/A

• Emergency kits available for diabetic students in the event of a lockdown or evacuation.

  Yes

  No

  N/A
Insulin orders

• DMTP insulin dose matches Skyward Med Entry/current dose or insulin correction ratio

  Yes

  No

  N/A

• Parent written request for insulin change documented

  Yes

  No

  N/A

• Addendum orders on file if change is treated than allowed by DMTP

  Yes

  No

  N/A
Continuous Glucose Monitor (CGM)

• Student initials with CGM

• CGM parent acknowledgement and permission form is complete

  Yes

  No

  N/A

• Student self-monitors CGM

  Yes

  No

  N/A

• Insulin dosing requested using CGM glucose values.

  Yes

  No

  N/A

• CGM is FDA-approved for insulin dosing

  Yes

  No

  N/A

• Intra-target insulin dosing requested (micro-boluses)

  Yes

  No

  N/A

• Written order for CGM use for insulin dosing received

  Yes

  No

  N/A

• Parent has provided staff CMG access via app

  Yes

  No

  N/A

• CGM data accessed on district-owned device only (no staff personal device monitoring)

  Yes

  No

  N/A

Emergency Preparedness

• Emergency care forms are printed and available to be quickly taken during an evacuation OR forms are saved to campus nurse laptop.

  Yes

  No

  N/A

• EMS envelopes for identified students are readily available for student health emergency (include Emergency Care form, Student health history, physician orders, action plans, etc.)

  Yes

  No

  N/A

• Evacuation plan in place for medications, special procedure supplies/equipment

  Yes

  No

  N/A

• Emergency bag/cart is intact, readily accessible.

  Yes

  No

  N/A

• Laptop power cord located in emergency go box.

• AED daily, monthly, annual check offs done.

• Campus Response Team has been identified for emergencies including medical/AED.

  Yes

  No

  N/A

• Campus Response Team training/drills planned or held

  Yes

  No

  N/A

• Emergency Guidelines for Office Staff notebook available.

  Yes

  No

  N/A

• Plan in place for entry into locked clinic bathroom door.

  Yes

  No

  N/A

• Documented evacuation chair training on file for 2 story campuses.

  Yes

  No

  N/A

Substitutes

• School Information

• Sub welcome letter with school specific information included

  Yes

  No

  N/A

• School Staff Information

• Current telephone list of nurse extensions and campus buddy nurse is accessible.

  Yes

  No

  N/A

• Process for documentation clearly defined.

  Yes

  No

  N/A

• Daily Schedule

• Current daily med worksheet available?

  Yes

  No

  N/A

• Bell Schedule/Specials Schedule is available

  Yes

  No

  N/A

• Student Health Concerns

• Current student health condition information is readily available.

  Yes

  No

  N/A

• General Student Information

• Alpha Rosters available if appropriate

  Yes

  No

  N/A

• Disaster Preparedness

• Emergency procedures and contacts for campus.

  Yes

  No

  N/A

• Map of building including AED locations is available.

  Yes

  No

  N/A

• Supplies and Forms

• Detailed explanation of special procedures is available.

  Yes

  No

  N/A

• Location of special procedures, emergency supplies, diabetes supplies clearly labeled.

  Yes

  No

  N/A

• Other

• RN guidelines manual visible/available.

  Yes

  No

  N/A

• Campus sub coordinator had a copy of most current nurse sub list.

  Yes

  No

  N/A

Professional Nursing Practice

• Professional Development hours complete.

  Yes

  No

  N/A

• Classroom/student education done according to health TEKS and/or campus-student health needs:

• Handwashing signs posted on campus

• Cold and flu education; respiratory etiquette

• Newsletter and parent health information

• Parent head lice information- Not positive find notices.

• Growth and development presentation for 5th grade

• Other health education:

  Yes

  No

  N/A

• Special event/committee involvement?

  Yes

  No

  N/A

• Nurse is wearing name badge with credentials displayed.

  Yes

  No

  N/A

Staff Signatures

• School Nurse

  Sign

• Coordinator of Health Services

  Sign