Comprehensive School Health Program

  • School health office orderly and free of clutter.

  • What needs to be organized/cleaned?

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

  • What is not working?

  • Gloves are readily accessible in clinic.

  • 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)?

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

  • 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.

  • Audiometer monthly biological check offs done.

  • Clinic stats reported every month.

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

  • Disposable items are unexpired, undamaged, not discolored and latex-free (bandages, tape, etc)

  • Temperature Reading Chart Completed

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.

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

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

  • IHPs have been created or updated for identified students.

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

Medication and Special Procedures. FFAC (legal and local)

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

  • Are there 2 unique patient identifiers?

  • Select all that apply

  • Drug information is included for new (or uncommon medications) in the medication book.

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

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

  • Monthly check offs of standing order medications is complete.

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

  • 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).

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

Inventory of Controlled Medications

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

Unlicensed Assistive Personnel

  • Principal Medication Designation form is complete and easily accessible

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

  • Delegation Form Completed for procedures that are delegated.

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


  • Level 1 training is completed and documented

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

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

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

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

Diabetes Care

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

  • DMTP insulin dose matches Skyward Med Entry/current dose or insulin correction. If different from DMTP, there are insulin change forms on file.

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

  • UDCA Principal Designation Form is signed

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

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

  • Continuous Glucose Monitor (CGM)
  • CGM parent acknowledgement and permission form is complete

  • Student self-monitors CGM

  • Insulin dosing requested using CGM glucose values.

  • CGM is FDA-approved for insulin dosing

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

  • Written order for CGM use for insulin dosing received

  • Parent has provided staff CMG access via app

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

Emergency Preparedness

  • Emergency care forms are saved to campus nurse laptop.

  • EMS envelope for identified students are readily available for student health emergency (Include Emergency Care Form, Student Health History, Physician Orders, Action Plans, etc.)

  • Emergency bag/cart is intact, readily accessible.

  • Stop the Bleed kits are in the AED boxes with sticker indicating location

  • Laptop power cord located in emergency go box.

  • Emergency plan in place for medications, special procedure supplies/equipment. (Glucose gel/tabs, Glucagon, Seizure meds, tube feeding supplies, etc)

  • AED daily, monthly, annual check offs done.

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

  • How many staff are trained in CPR

  • Campus Response Team training drill held or planned

  • Emergency Guidelines for Office Staff notebook available.

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


  • Sub welcome letter with campus specifics included.

  • Map of building with AED location(s) noted

  • Current Nurse Extension list with buddy nurse noted

  • Current daily medication worksheet is available.

  • Current health condition list is printed in binder.

  • Detailed explanation of evacuation procedures including medications, special procedure supplies, and diabetes care is readily available.

  • RN guidelines is accessible

  • Campus sub coordinator has a copy of the current nurse sub list.

Professional Nursing Practice

  • Professional Development hours complete

  • Goal for this year- Enter in Strive

  • Nurse is wearing name badge with credentials displayed.

Staff Signatures

  • School Nurse

  • Coordinator of Health Services

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