School Health Services Walkthrough Fall

• Site

  Select

• Campus Nurse

• Conducted on

  Date

• Prepared by

Comprehensive School Health Program

• School health office orderly and free of clutter.

  Yes

  No

  N/A

• What needs to be organized/cleaned?

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

  Yes

  No

  N/A

• What is not working?

• 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 (uploaded under Enrollment tab). Original form kept in file.

  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.

  Yes

  No

  N/A

• Clinic stats reported every month.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Temperature Reading Chart Completed

  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 and EAPs have been created or updated for identified students.

  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 ID number

  • medication bottle picture
  • medication form picture
  • Date of Birth
  • ID number

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

  Yes

  No

  N/A

• 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. Medications are available.

  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.

  Yes

  No

  N/A

• 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) for each controlled medication on file in the clinic. Inventory reconciliation documents should be kept in the medication binder.

  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

• Delegation Form Completed for procedures that are delegated.

  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

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

  Yes

  No

  N/A

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

  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
Continuous Glucose Monitor (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 saved to campus nurse laptop.

  Yes

  No

  N/A

• EMS envelope 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

• Emergency bag/cart is intact, readily accessible.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Laptop power cord located in emergency go box.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• AED Sign Visible

  Yes

  No

  N/A

• AED daily, monthly, annual check offs done.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• How many staff are trained in CPR

• Campus Response Team training drill held or planned

  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

Substitute

• Sub welcome letter with campus specifics included.

  Yes

  No

  N/A

• Map of building with AED location(s) noted

  Yes

  No

  N/A

• Current Nurse Extension list with buddy nurse noted

  Yes

  No

  N/A

• Current daily medication worksheet is available.

  Yes

  No

  N/A

• Current health condition list is printed in binder.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• RN guidelines is accessible

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Professional Nursing Practice

• Goal for this year- Enter in Strive

  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