PASADENA UNIFIED SCHOOL DISTRICT

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1 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS PROCEDURE GUIDE Board of Education Renatta Cooper Tyron Hampton Kimberly Kenne Mikala Rahn Elizabeth Pomeroy Tom Selinske Scott Phelps Jon Gundry Jon Gundry Ann Rector President Vice-President Member Member Member Member Member Superintendent of Schools and Secretary to the Board of Education Coordinator of Health Programs

2 ACKNOWLEDGMENTS A number of people contributed significantly to this Procedure Guide. We are deeply grateful to the Pomona Unified School District for their Guide which was used as a model for the development of this Procedure Guide; to Louise Singleton, School Nurse Practitioner and Consultant, who dedicated many hours to reviewing, correcting, and revising each procedure; and to the Pasadena Unified School District Nurses and Nurse Practitioners who also provided many hours reviewing the procedures and assisting with revisions and additions. A special thank you also to the Los Angeles County Office of Education, Educational Support Services Division for providing sample procedures and reviewing the Guide, and to the State of California Department of Education for Education Code Regulations, legal support, and new laws. This book addresses just some of the current challenges facing the nurse in the school setting. Without the help of the above mentioned agencies and individuals, this valuable resource would not have been possible. Rev. 08/09/2013

3 Table of Contents Section I - General Information I. General Information A. Program Outline...1 B. Credentialed School Nurse 1. Job Description Job Description Credential School Nurse/Nurse Practitioner Specific Services Provided by the Certificated School Nurse Mandated Services Health Office Monthly Activities - Suggested Guidelines Orientation Checklist Evaluation a. Guidelines b. Forms c. Goals Worksheet C. Health Clerk 1. Job Description/Responsibilities Health Clerk Guidelines Manual Evaluation Forms Memo Student Immunizations and Medical Conditions Medical Code List D. Responsibilities of Office Personnel E. Report Forms 1. Daily Health Office Log Monthly Reports...41, 42, Monthly Reports First & Second Semester....44, 45, 46, 47 F. Lists 1. Casts/Crutches/Wheelchair Rev. 08/09/2013

4 Table of Contents (cont d) 2. Communicable Diseases Medications Special Health Concerns (Old Liability List) G. Referral List 1. Counseling Hearing Medical Care SST Meetings Vision Young & Healthy H. Follow Up 1. Referral for Health Care Request for Follow-up Health Update..62 I. Specific Diseases Letters/Forms 1. Asthma a. Guidelines b. Standard School Emergency Response c. Asthma Information Log d. Parent Letter e. Parent Guidelines for School Attendance f. Asthma Survey Consent g. Asthma Survey h. Administration of Medication i. Nebulizer Consent Letter j. Asthma Episodic Log Rev. 08/09/2013

5 Table of Contents (cont d) k. Asthma Algorithm l. Emergency Care Plan Diabetes a. Letter to Parent b. Blood Glucose Graph c. Type 2 Diabetes Information letter...88,89, J. Health Office Information 1. Sample of Student Health Record Pupil Health Office Visit Card Health Office Student Pass Emergency Card Information Sample of Emergency Card Flagging of Health Records Health Office Supplies a. Ordering b. List c. Warehouse Order Form d. Outside Order Form Rev. 08/09/2013

6 Program Outline The Pasadena Unified School District through its Board of Education has maintained a long history of support for a comprehensive school health program. The program is designed to protect and promote the health and well being of all students and staff. This procedure guide for the health service staff is only one part of a comprehensive school health system that includes health education, physical education services, psychological counseling services, a safe and healthy school environment, and health promotion for staff, parent, and community involvement. A school based health program provides for early identification of health problems and expertise and leadership from the school nurse in triage and treatment for injury and illness including Red Cross First Aid and CPR Instruction for students (when appropriate) and staff. The following activities are the responsibility of each school nurse: Assessing school community Health Programs and educational needs. Providing mandated vision, hearing, and scoliosis screening, referral and follow-up as necessary. Ensuring adequate immunization status of students. Assisting in ensuring that special education pupils with extended learning and/or physical disabilities will be placed in appropriate classes or classroom settings. Providing nursing expertise to students, families, and staff as appropriate. Providing support and leadership regarding child abuse, case finding, reporting, and follow-up. Conducting health appraisals, screening, and follow-up. Providing teachers with resource materials and background for health-related education classes. Providing personal health counseling to students, parents, and staff as appropriate. Assisting families in need to obtain medical and social services. Implementing innovative programs which build upon student strengths and ensure optimal learning. Acting as liaison between the school and community resources. Providing health-related input and expertise to related district programs. Assessing the acutely ill and injured, and providing treatment and referral through the district clinic and other resources. Case Management The primary goal is to strengthen and facilitate the educational process by improving and protecting the health status of students and staff. Primary Health Care Clinic 351 S. Hudson, Room 130 The Pasadena Unified School District Primary Health Care Clinic, staffed by Nurse Practitioners, provides medical services for uninsured children, preschool through high school. Children receive complete physical examinations, CHDP exams, sports and camp physicals, and medical care for illness and injury. Other services include immunizations, tuberculosis screening tests, counseling, and health education. Referrals and appointments are made through school nurses and health clerks. This Clinic has a Title I outreach worker to assist families with accessing MediCal, Healthy Families, California Kids, and other health care plans for medical homes for children. Drug Prevention As part of a Comprehensive Health Education program, students receive instruction in drug prevention at all grade levels. The programs help students build self-esteem, improve peer relationships and learn to make healthy, drug-free choices. Rev. 08/09/2013 I - 1

7 POSITION TITLE: RESPONSIBLE TO: CREDENTIALED SCHOOL NURSE JOB DESCRIPTION Coordinator of Health Programs QUALIFICATIONS: 1. California licensure as a Registered Nurse 2. Baccalaureate Degree 3. Health Services Credential. (Possession of a Preliminary Credential may be acceptable.) ROLE: Strengthens the educational process through a comprehensive health program which focuses on improvement and protection of the health of pupils and school personnel in accordance with state law and district policy and procedures. POSITION RESPONSIBILITIES: Rev. 08/09/2013 I Identifies student health problems through case findings, and screening procedures. 2. Counsels students, parents and school personnel about illness, physical defects, social, and potential health problems. 3. Refers students needing medical or dental care. Assists families to solve financial, transportation and other barriers to health care. 4. Completes health assessment of Special Education candidates including social and emotional components of the family setting. Is a member of the I.E.P. team. 5. Conducts a communicable disease program directed toward the control of communicable disease in the school, including immunization assessment and compliance. 6. Maintains health records of students and documents care provided. 7. Informs teachers of health problems of students and suggests ways of preventing complications and enhancing a student s achievement potential. 8. Provides emergency care for seriously ill and injured students. 9. Counsels parents, pupils and school staff regarding health related attendance problems. Assists with Home Teaching referrals. 10. Supervises the administration of medications according to district policy.

8 11. Confers and communicates with physicians and other health professionals. 12. Assists site staff in the referral process for suspected child abuse. 13. Serves as a liaison to community agencies. 14. Supports professional health career programs. 15. Reports health problems of students and school environment to administrators. Assists in the identification of safety and health hazards. 16. Maintains first aid supplies including kits for classroom. 17. Supervises work of clerical personnel and student helpers in health office. 18. May participate in teaching school personnel First Aid and CPR to meet immediate needs of students and staff. 19. Serves as a resource and consultant in health education. Teaches health education topics in the classroom. 20. Maintains professional competence through participation in inservice education activities. Rev. 08/09/2013 I - 3

9 POSITION TITLE: RESPONSIBLE TO: MINIMUM REQUIREMENTS: CREDENTIALED SCHOOL NURSE/NURSE PRACTITIONER JOB DESCRIPTION Coordinator of Health Programs 1. Master's degree with a major in nursing from an appropriately accredited institution of higher learning and completion of an accredited nurse practitioner program. 2. Must hold a valid California Registered Nurse license and a valid California Nurse Practitioner license. 3. California Health Services Credential. DESIRABLE QUALIFICATIONS: 1. Two years experience as a nurse practitioner. RESPONSIBILITIES: Rev. 08/09/2013 I Two years experience as a school nurse and/or public health nurse. 3. Holds national professional certification. 4. Knowledge of bilingual, bicultural healthcare and health practices. 5. Experience working with an urban, multiethnic population. 6. Knowledge of state and federal regulations regarding funding sources for provision of medical care. 7. The ability to communicate effectively in both written and oral forms. 8. The ability to work effectively and cooperatively with professionals, paraprofessionals and community groups. 9. Availability of private transportation. Under direction of the Director of Health Programs and supervising physicians per protocols, provides health services. The nurse practitioners performs assessments, makes a diagnosis, develops and implements a treatment plan including student and family education, provides follow-up and evaluation of client status and interacts with professional colleagues to provide comprehensive care. The nurse practitioner is qualified to perform all duties described under the school nurse job description in addition to the above responsibilities according to assignment. The major focus of school nursing is prevention of disabilities through early detection and correction of health problems and provision of a comprehensive service/education program for staff, parents and students. In addition the nurse practitioner is responsible for maintaining school based clinic including supervising staff, clinic operations, quality assurance, managing funding, and grant writing.

10 EXAMPLES OF DUTIES: 1. Performs direct primary care such as complete physical examinations, including head to toe exam, ordering indicated lab work and studies, immunizations, and anticipatory guidance on all children. 2. Employs strong focus on adolescent health care and prevention through identification of at risk behaviors utilizing the Guidelines for Adolescent Practice. 3. Conducts preventive screening procedures based on age and history. 4. Performs evaluation, diagnosis, treatment and follow-up for common acute and routine chronic illness. 5. Furnishes pharmacological agents and non-pharmacological therapies per protocol. 6. Identifies needs of the individual, family and/or community as a result of the evaluation of the collected data, and facilitates appropriate utilization of the healthcare system. 7. Updates and records changes in health status. 8. Maintains communication with parents, school staff, and involved community practitioners or agencies to promote needed treatment and secures reports of findings pertinent to educational planning. 9. Administers immunizations and TB tests for all students, employees and volunteers within the district. 10. Provides employee pre-employment physical examinations. 11. Consults and serves as a resource person to teachers, staff, and administrators involved in the school programs. 12. Provides in-classroom health education. 13. Participates in quality assurance review on a periodic basis including regular chart review 14. Nurse practitioners combine the roles of provider, educator, manager and consultant. They act as a preceptor with numerous educational institutions i.e.: UCLA, USC, CSULA, and Azusa Pacific. 15. Performs other duties, as assigned. Rev. 08/09/2013 I - 5

11 SPECIFIC SERVICES PROVIDED BY THE CERTIFICATED SCHOOL NURSE 1. Hearing Assessment. 2. Vision assessment. 3. General health assessment of children. 4. Counseling students with physical, social and emotional problems. 5. Counseling parents regarding health problems affecting the student s achievement. 6. Assisting parents with appropriate referrals for further diagnosis and treatment of their child s health problems. 7. Assisting families with financial barriers to treatment. 8. Consulting with teachers regarding student s health problems and their adjustment in the classroom. 9. Continuous monitoring of community resources to meet student s needs. 10. Managing communicable disease outbreaks in conjunction with the Pasadena Health Department or the County Health Department. 11. Assisting school personnel in the recognition of signs and symptoms of communicable disease. 12. Consulting with teachers on up-to-date and scientific health information. 13. Assisting teachers with resources for health education. 14. Giving lessons in health education in the classroom. 15. Staff inservices on a variety of health topics. 16. Providing Mantoux skin tests for students and employees at the district clinic. 17. Assessment, referral and administration of required immunizations for students at the district clinic. 18. Providing American Red Cross First Aid and CPR Training for students and staff. 19. Certifying student illness for admission to home teaching. 20. Certifying student illness in special attendance problems, and counseling student and parents. Rev. 08/09/2013 I - 6

12 SERVICES PROVIDED BY THE CERTIFICATED SCHOOL NURSE (CONTINUED) 21. Screening of students referred to Student Study Team to identify or rule out problems that may interfere with achievement in the classroom. 22. Health assessment, including neuromaturational development, of students referred for evaluation by Guidance Team. 23. Referral for complete physical examination (excluding X-ray and special tests requiring laboratory work) to the district clinic for the student who qualifies financially under CHDP and Medi-Cal requirements. 24. Specialized physical health care services to qualifying student (e.g., catheterization, tracheostomy care, gavage feeding). 25. Crisis intervention. 26. Bereavement counseling of students dealing with death or other serious loss. 27. Assisting school staff in preparing for earthquakes and other disasters. 28. IEP assessment, screening and written report. Services may be obtained by referral from a teacher, psychologist, speech therapist or any other staff person, student self-referral, physician or other private practitioner referral, community agency referral, or parent request. Rev. 08/09/2013 I - 7

13 MANDATED SCHOOL NURSING ACTIVITIES ON DISTRICT TIME School nursing activities are mandated in the California Education Code (CEC) Title 5 or Health and Safety Code (H & SC). Health Education is also mandated and the school nurse initiates, facilitates, and serves as a resource to the classroom teacher. Mandates include special education assessment which is under the direction of that department. MANDATES PRIORITIES OF THE DAY CEC a. Crisis intervention: Child abuse, rape, serious traumas, serious illness, pregnancy, suicide attempts, drug ingestion, and other emotional crisis as well as needed screening. H & SC b. Immunizations and reporting of immunizations (students need immunization to be admitted to school). PROGRAM PRIORITIES CEC Vision (including color) and hearing screening, referral and follow-up. 455, Identification of other health problems, referral and follow-up. 3. Communicable disease control (i.e., pediculosis, scabies, shigella and childhood diseases). C E C C E C Scoliosis screening, referral and follow-up. 5. Dental disease identification, referral and follow-up. 6. Attendance counseling of students and parents regarding health related absences (home visits on request from principal). 7. Follow-up on all identified problems including those identified in the CHDP examinations. 8. Annual and other special reports, maintenance of student records including special education records and other reports. 9. Life process and other health education activities. 10. Dental education at appropriate elementary grade levels. A definition of diligent care (CEC 49400) has come from the State Department of Education: A public education agency does have the responsibility of ensuring that all pupils receive diligent care related to their health needs and physical development (see Education Code Section et. Seq.). This means that public education agencies must be involved in screening, consultation and referral activities which will assist parents in obtaining proper medical treatment for their child. Rev. 08/09/2013 I - 8

14 HEALTH OFFICE MONTHLY ACTIVITIES SUGGESTED GUIDELINES SEPTEMBER 1. Before school begins or as soon as possible, discuss current mandatory immunization guidelines with office staff. Confirm need for written verification of Immunization status. Clarify procedure for referral to Health Programs Immunization Clinic. See current flyer. 2. Compile a list of students with waivers of immunizations. This must be current if exclusions become necessary. 3. Check supply of forms, first aid supplies and arrange health room cupboards. 4. Prepare/distribute first aid kits and latex gloves to the classroom and noon-duty personnel. In secondary schools, distribute to home economic, shops, labs, etc. Gloves distributed to all staff per OSHA guidelines. 5. Begin preparing a list of students with significant health problems - Health Concerns list. Distribute to appropriate staff, maintaining confidentiality rights of students. Serious health problems should have treatment strategies outlined. Copy to be sent to Health Programs Coordinator. 6. Make a list of students with parental waivers excluding first aid/medical treatment. Post a list of those names on the inner door of the first aid cabinet. 7. Visit each classroom, introduce yourself and explain your function and procedures. 8. If possible, attend the first staff meeting to become acquainted with new teachers. This meeting often occurs before school begins. 9. Request office staff to inform you of any new student who reports a physical problem at the time of enrollment. Review enrollment forms. 10. Notify all office personnel of daily schedule for nurse, health clerk, and procedures to follow when emergencies occur. Obtain current school nurse on call list. 11. Set up file or notebook to expedite follow-up activities on students. 12. Review special education class lists for needed assessments and required designated instructional services. Determine timeline. 13. Plan conferences with teachers to inform them of individual student health needs. Rev. 08/09/2013 I - 9

15 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED) SEPTEMBER (CONTINUED) 14. Send CHDP letters home to all 1st graders who do not have CHDP certificates. Check CHDP worksheet from previous year. Check procedures for CHDP program. May send letter informing parents of CHDP availability and qualifying requirements for students in grade Begin Kindergarten immunization audit report. Forms will come from the Health Department. Instructions for completing should be followed closely. Submit to coordinator for district compilation. 16. Become familiar with the cumulative health records of each student so you may understand individual health status and develop intervention strategies. Prepare health folders for students new-to-district. 17. Prepare a list of parent volunteers to assist during screening and other activities. 18. List all students requiring medication in school. Train staff who will be responsible in the absence of nurse and Health Programs assistant. Complete sign-off sheet. 19. List all students requiring assistance with specialized health procedures. Train staff who will assist student and complete sign-off sheet. 20. Schedule with principal time to present certificated and classified staff inservices on mandated subjects (e.g., blood borne pathogens & child abuse identification and reporting). 21. Monthly report due. OCTOBER 1. Continue nurse-teacher conferences so the teacher is current with health needs of students. 2. Attend staff meetings if relevant to health programs. 3. Schedule and conduct hearing and vision testing. Make appropriate referrals. Record results of testing programs on health folder as soon as possible and develop format for keeping yearly totals up-to-date. (Annual reports due June 1st.) 4. Meet with parent groups. Discuss health education articles for their newsletters. Offer assistance such as participation in health education programs for meetings, as time permits. Rev. 08/09/2013 I - 10

16 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED) OCTOBER (CONTINUED) 5. Continue follow-up on previously referred students including special education. 6. Initiate vision and hearing on all new enrollees. Report results to teachers. Discuss with teachers their observations before contacting parents to report deviations. 7. Continue immunization program monitoring. 8. Attend parent night presentations for 5th, 6th, 7th, & 9th grade Human Growth Lessons. 9. Schedule 5th grade Human Growth lessons. 10. Provide Coordinator of Health with updated copy of Health Concerns list. 11. Monthly reports due. 12. As soon as possible, schedule vision and hearing screening date. Grades K, 2nd, 5th, 8th, and 10th, and Special Education students. NOVEMBER 1. Test vision and hearing of all new enrollees if it hasn t been done within the last two years. 2. Continue to follow-up on all referrals. 3. Continue follow-up on CHDP letters of first graders and others, as appropriate. 4. Continue immunization program monitoring. 5. Continue vision and hearing screening. 6. Schedule scoliosis screening at middle schools. 7th grade girls and 8th grade boys are mandated and will be done by the Screening Team in January or February. 7. Attend annual CPR recertification class. 8. Monthly report due. 9. Schedule Kindergarten hand washing class. Rev. 08/09/2013 I - 11

17 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED) DECEMBER 1. Continue testing, referral and follow-up on new and referred students. Record those receiving care. 2. Restock first aid boxes whenever needed. 3. Continue immunization program monitoring. 4. Continue follow-up on CHDP program. Secure waivers where appropriate. 5. Gather data for CHDP report (due to state January 15th). 100% compliance is mandated. 6. Prepare for the dental education/inspection program in February. Gather materials, confirm with dentist. Organize parent volunteers. 7. Continue vision and hearing screening. 8. Monthly report due. JANUARY AND FEBRUARY 1. Schedule dental education class for 1 st graders 2. Conduct dental inspections with volunteer dentist. Refer for care. 3. Be alert for early signs of communicable disease. Staff and parent education is an important part of communicable disease control (appropriate for all year, but winter months are frequently flu months.) 4. Evaluate progress in testing program. Continue testing, referrals and follow-up. 5. Continue immunization program monitoring. 6. Continue immunization follow-up on referrals including special education. 7. Send CHDP letter to kindergarten students and assist in scheduling at clinic. 8. Continue all types of health education. 9. Schedule color vision on K or 1st grade males. Complete and record. 10. Conduct mandated scoliosis screening. Refer and record. 11. Monthly report due. Rev. 08/09/2013 I - 12

18 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED) MARCH AND APRIL MAY JUNE 1. Schedule 6th grade human growth lessons. 2. Continue to arrange time with teachers for teacher-nurse conferences. 3. Continue immunization program monitoring. 4. Continue testing and referral for vision, hearing and scoliosis on new and referred students. 5. Continue follow-up on all referrals including special education. 6. Continue Health Education. 7. Monthly report due. 1. Complete all follow-up on referrals for any assessment or screening. 2. Monthly report due. 1. Enlist teacher cooperation in encouraging parents and children to follow up with identified health problems during summer vacation. 2. Forward copies of students with health problems who are being promoted to middle school/high school to nurses at these schools. 3. Request that teachers and other personnel return first aid kits issued in September. Clean and store kits. 4. Store equipment left at site in a locked cabinet or area. 5. Return audiometers to health office for calibration. Return any equipment needing repair. Rev. 08/09/2013 I - 13

19 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED) JUNE (CONTINUED) 6. Submit the following reports to Health Programs: - Health Concerns list of promoted students (also send to receiving site) - Immunization Concerns List of promoted students (also send to receiving site) - Annual Vision Report - Annual Hearing Report - Scoliosis and Orthopedic Screening Report - Monthly Report 7. Obtain list of special education students attending summer school, and forward to summer school nurses (Health Concerns). Rev. 08/09/2013 I - 14

20 ORIENTATION CHECKLIST SCHOOL NURSE A GUIDELINE CHECKLIST TO ASSIST SCHOOL NURSES IN COMPLETING THEIR ORIENTATION RESPONSIBILITIES. I. IMMUNIZATIONS Contact - Immunization Clinic Facilitator/Health Programs Coordinator Procedure for referrals to Area Clinics Completion of Kindergarten Immunization Audit Mantoux Audit Students with immunizations waivers Immunization recording on student files Familiarization with immunization clinic (Inservice training in immunization and mantoux procedures) Forms and additional information in the Health Programs Procedure Guide. II. III. VISION AND HEARING SCREENING Contact - Health Resource Specialist/Screening Team Facilitator Inservice on Snellen and Kindergarten screenings Inservice on Audiometers Scheduling and organizing classroom time Referrals Recording results Color vision on K or 1st grade males Forms and additional information in the Health Programs Procedure Guide. HEALTH EDUCATION TO STUDENTS (Examples) Contact - Unit Leaders A. Kindergarten Handwashing Lessons (Communicable disease prevention) Scheduling classroom presentations Availability of prepared lesson plans, i.e., Scrubby Bear Acquirement of Health Education materials Observation of other nurses B. First Grade - Dental Health Scheduling classroom presentations Availability of prepared lesson plans Acquisition of Health Education materials Observation of other nurses Scheduling screening with assigned dentist Referrals Organizing parent volunteers for dentist screening Familiarization with resource Manual Rev. 08/09/2013 I - 15

21 C. Fifth Grade Family - Growth and Development Information to parents/staff via letter Scheduling classroom presentations Acquisition of Health Education materials Availability of prepared lesson plans and videos Observation of other nurses D. Sixth Grade - Human Reproductive System Information on HIV to parents/staff via letter Scheduling classroom presentations Acquisition of Health education materials Availability of prepared lesson plans and videos E. Seventh Grade - Contraception Information to parents (letter) Scheduling of classroom presentations Acquisition of Health education materials (may have Planned Parenthood speakers) Availability of prepared lesson plans and video (7th grade health curriculum) Observation of nurses to other speakers F. Ninth Grade - CPR instruction CPR instructor certification from American Heart Association or American Red Cross. Scheduling of classes with health teacher Maintenance of mannequins IV. SPECIAL EDUCATION A. School Nurse Role in Special Education Health assessment done by school nurse Medical referrals and follow up Writing of Goals/Objectives for I.E.P. (Individualized Education Program) as related to medical/health needs Visitation to facilities/classroom Referral and screening process Completion of Monthly Report and State School Register D.I.S. book B. Programs available (Upon completion of Special Ed. Assessment) Special Day Class (SDC) Resource Specialist Program (RSP) Adaptive Physical Education Pre-K and Preschool Program California Children s Services (CCS) (Roosevelt School) Rev. 08/09/2013 I - 16

22 V. CHILD HEALTH AND DISABILITY PREVENTION PROGRAM (CHDPP) Contact - CHDP Clinic Lead Nurse Practitioner Parent permission release for physical exam CHDP eligibility Scheduling at health clinic Review procedures for CHDP Program School nurse follow-up on medical/health referral as needed Familiarizing self to clinic CHDP Annual Report due December for 1st Graders Forms and additional information in the Health Programs Procedure Guide. VI. VII. VIII. IX. REFERRAL SERVICES WITHIN THE COMMUNITY Assisting parents with appropriate referrals Assisting families with financial barriers to treatment Monitoring of community resources Referrals and follow-up YOUNG AND HEALTHY Contact - Staff at Young and Healthy Eligibility Familiarization with forms and referral procedures SUSPECTED CHILD ABUSE Contact - Health Programs Coordinator Understanding how child abuse is handled in PUSD State and Federal Law Assisting site staff in recognition and referral process for suspected child abuse cases Forms and additional information in Health Programs Procedure Guide. MEDICATIONS Contact - Health Programs Coordinator Listing of all students at your site requiring medication while at school Daily Log/Sign-off sheet Orientation of appropriate school personnel on absence of school nurse Proper administration and storage of prescribed medications X. EMERGENCY PROTOCOL/FIRST AID Contact - Health Programs Coordinator Providing emergency care/when to call 911 Inservice to site staff on emergency first aid What to do when parent cannot be contacted Emergency Card/Letter to parents Accident Report Classroom first aid box Forms and additional information in Health Programs Procedure Guide. Rev. 08/09/2013 I - 17

23 XI. XII. XIII. XIV. XV. XVI. UNDERSTANDING CHAIN OF COMMAND Faculty Administrators SUPERVISION OF CLERICAL PERSONNEL Contact - Health Programs Coordinator Orienting health clerk Supervising and coordinating work of health clerk Familiarization with health clerk duties HOME TEACHING SERVICES Contact - Home and Hospital School Health Programs Assistant/Clerk Certifying students illness Admission to home teaching/monitoring of services Completion Reports Forms and additional information in Health Programs Procedure Guide. COMMUNICABLE DISEASE Contact - Coordinator Inter-communication with county or city health department Education of site staff on signs and symptoms of communicable disease Notification to parents Forms and additional information in Health Programs Procedure Guide. LEA Medi-Cal Billing Contact - Health Programs Medi-Cal Program Assistant Provider I.D. number Purposes and procedures for completing forms Eligible services System/partnership with Health Clerk Form completion and follow through responsibilities Forms and additional information in Health Programs Procedure Guide and LEA Provider Resource Book. GENERAL INFORMATION Contact - Health Programs Secretary Evaluations Mileage/travel reimbursement Ordering supplies Daily Log/monthly tally Forms and additional information in Health Programs Procedure Guide. Rev. 08/09/2013 I - 18

24 Pasadena Unified School District Evaluation/Supervision - Non Instructional Certificated Employees The Superintendent or designee shall ensure that certificated employees have access to written regulations related to the evaluation of their performance in their assigned duties. (Education Code 35171) (cf Probationary/Permanent Status) (cf Competence in Evaluation of Teachers) Non instructional certificated employees shall be evaluated on their performance in fulfilling their defined job responsibilities. (Education Code 44662) Evaluations shall include recommendations, if necessary, as to areas of improvement in the employee s performance. If an employee is not performing satisfactorily according to standards approved by the Board, the Superintendent or designee shall so notify the employee in writing, describing the unsatisfactory performance. The Superintendent or designee shall also confer with the employee, make specific recommendations as to areas of improvement, and provide assistance to the employee. (Education Code 44664) Non-instructional certificated staff members employed on a 12-month basis shall receive a copy of their evaluation no later than June 30 of the year in which the evaluation is made. Before July 30 of the year in which the evaluation takes place, the employee and the evaluator shall meet to discuss the evaluation. (Education Code 44663) Rev. 08/09/2013 I - 19

25 PASADENA UNIFIED SCHOOL DISTRICT Pasadena, California Self- and Summative Evaluation for Non-Teaching Certificated Personnel Name of Evaluatee Name of Evaluator Date Location NA Not Applicable 1. Does not meet 2. Needs improvement 3. Meets 4. Exceeds I. DEVELOPING STAFF PERSONNEL A. Maintains good staff morale. N/A B. Is approachable. N/A C. Emphasizes the importance of team work. N/A D. Maintains effective communication. N/A E. Shows sensitivity as evidences by understanding of others, empathy, and acceptance of others point of view. N/A Evaluator Comments: Evaluatee Comments: II. JOB PERFORMANCE A. Performs those duties as established for the respective positions. N/A B. Communicates effectively in oral and written form. N/A C. Exhibits creativity by innovation, flexibility and initiative. N/A D. Demonstrates knowledge of current research findings and trends. N/A E. Assists staff to achieve goals which improve the program in area served. N/A F. Provides a good working environment as evidenced by attention to staff needs and suggestions. N/A G. Supports learning opportunities for students and/or provides services for students. N/A Evaluator Comments: Evaluatee Comments: Rev. 08/09/2013 I - 20 FM 651 WSN0553 Rev 12/94

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27 III. PROFESSIONAL RESPONSIBILITY A. Assumes responsibility for records, materials, and equipment. N/A B. Seeks appropriate help when needed; accepts supervision in a positive manner. N/A C. Works constructively with staff and students. N/A D. Conducts workshops, demonstrations, and inservice trainings. N/A E. Effectively assists in the development and implementation of behavior management. N/A F. Displays knowledge of community resources and utilizes and refers when appropriate. N/A G. Works and communicates effectively with parents and the community. N/A H. Participates in professional growth activities. N/A Evaluator Comments: Evaluatee Comments: IV. IMPLEMENTING SCHOOL POLICIES A. Carries out instructions properly. N/A B. Is consistent in the administration of policies and rules. N/A C. Adheres to Board policies as well as appropriate state regulations and laws. N/A Evaluator Comments: Evaluatee Comments: Assistance Recommended: Evaluator s Signature Evaluatee s Signature FM 651 WSN0553 Rev 12/94 DISTRIBUTION: Original to Personnel Department, first copy for employee, second copy for school or office. SIGNATURES: This report has been discussed with me and signing this report does not necessarily mean that I agree with all the ratings. Both the evaluator and the evaluatee shall date and sign the report. In case the evaluatee refuses to sign the report, the evaluator shall request a witness to sign as evidence that the conference has been held.

28 SUMMARY STATEMENT Current employment status (check one) (DATE) Permanent Probationary Temporary Evaluator s Recommendation I. Recommended for continued employment III. Performance is unsatisfactory recommended for Assistance and evaluation as outlined for the II. Recommended for continued employment with school year. assistance and evaluation as outlined for the school year. Assistance recommended (use additional sheets if necessary) Assistance recommended (use additional sheets if necessary) FM 651 WSN0553 Rev 12/94 IV. Performance is unsatisfactory (Evalator s Signature) DISTRIBUTION: Original to personnel deprtment, first copy for employee, second copy for school or office. (Evaluatee s Signature) SIGNATURES: This report has been discussed with me and signing this report does not necessarily mean that I agree with all the ratings. Both the evaluator and the evaluatee shall date and sign the report. In case the evaluatee refuses to sign the report, the evaluator shall Request a witness to sign as evidence that the conference has been held.

29 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS TO: FROM: SUBJECT: Ann Rector, Coordinator of Health Programs Nurse Evaluation Input EMPLOYEE: SCHOOL: DATE: Please indicate below your assessment of this employee. 1. Responds with warmth and communicates effectively with children Excels Above Average Satisfactory Needs Improvement Unsatisfactory 2. Works cooperatively with and communicates effectively with our staff. 3. Works cooperatively with and communicates effectively with parents. 4. Provides effective consultive services. 5. Supports District/school policies. 6. Keeps scheduled time commitments. COMMENTS: Principal Rev. 08/09/2013 I - 23

30 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS Page NAME YEAR SCHOOL POSITION GOALS/MAJOR ACTIVITIES Beginning Date Completion Date Status * * STATUS: In planning; Operational; Completed Rev. 08/09/2013 I - 24

31 POSITION TITLE: HEALTH CLERK JOB DESCRIPTION: Under the direction of the Health Programs Coordinator and the supervision of the school nurse, assists in the daily operation of the School Health Office; administers first aid to ill and injured students, and performs a variety of clerical duties relating to the school health program. QUALIFICATIONS: KNOWLEDGE OF: 1. CPR and First Aid principles and techniques (certification required) 2. Child Abuse reporting requirements and procedure 3. Confidentiality of medical information 4. General clerical and record keeping procedures 5. Correct English grammar, spelling and usage ABILITY TO: 1. Effectively use required knowledge to carry out job duties in accordance with state laws and district regulations 2. Work cooperatively and effectively with children and adults 3. Analyze situations accurately and adopt an effective course of action 4. Meet schedules and time lines 5. Follow confidentiality requirements 6. Perform work independently with minimal direction 7. Operate office equipment, i.e. computer, typewriter and copier 8. Type 30 wpm GENERAL RESPONSIBILITIES: 1. Admits and supervises ill and injured students in the Health Office. Performs routine first aid and screens ill students. Notifies parents of injuries and students too ill to remain in school. Maintains a daily log with adequate documentation. 2. Communicates significant illnesses or injuries to school nurse and/or building administrator. Administers CPR immediately when necessary. Fills out accident reports. Rev. 08/09/2013 I - 25

32 3. Screens student records for adequate immunizations. Communicates needs to parents and excludes students for non-compliance according to policy. Prepares kindergarten immunization audit and TB report under supervision of school nurse. Maintains an accurate list of students exempted from immunization requirement. 4. Reviews records for CHDP documentation. Follows up with parents and CHDP clinic to schedule appointments and complete paperwork. Maintains a worksheet of all K and 1st grade students who have not provided proof of the required physical examination. 5. Administers medication supplied by parent with written orders from doctor and signed consent from parent under direction of the school nurse. 6. Prepares, distributes and maintains First Aid and Disaster First Aid Kits as directed by the school nurse. 7. Maintains adequate health office supplies. Prepares requisitions for the school nurse to approve. Replenishes daily supplies - ongoing. 8. Measures heights and weights as directed by the school nurse. 9. Makes health record for all kindergarten students and students new to the district. 10. Maintains health records and files. Duplicates materials as needed. Maintains emergency cards. Updates information. 11. Assists with the health screening programs performed by the school nurse. Records screening results on student record. Flags health records of students according to procedure. 12. Conducts classroom inspections for communicable disease under the direction of the school nurse. 13. Assists the nurse to maintain an accurate updated list of enrolled students with health problems. (Special Health Concerns List) 14. Follows California State law regarding Child Abuse reporting responsibilities. 15. Performs general clerical duties such as typing, distributing notices, etc. 16. Maintains the Health Office in a clean orderly manner. 17. Performs other duties as directed by the school nurse and/or school administrators. 18. Attends in-service training for specialized procedures and works under the supervision of the school. Rev. 08/09/2013 I - 26

33 HEALTH CLERK GUIDELINES MANUAL Beginning of School Year Procedures 1. Student programs: File alphabetically, divided by grade levels. 2. Filing: Set up manila folders for CHDP File Health, General Information Immunizations & TB Registration Information (RIs) - mark with current school year, - Hold & File RIs - New, Type 3. Registration forms (Rls): Divide RIs and attached forms into Transfer students (coming from a PUSD school) New students (coming from a school outside PUSD) Emergency cards Then alphabetize & place in manila folders. 4. Emergency cards (Procedure Guide [PG] I-61): File in alphabetical order and discard old cards after checking with Nurse. 5. Transfer Students: Check with Office Manager/Registrar re incoming transfer students, pull Health Records when ready and file. (see ). 6. Class List: Middle & High: Check with Data Control Clerk and request one class list each (two copies if Nurse would like one also), sorted alphabetically by last name to be delivered to Health Office once a month. You may also contact Rosemarie Riley at I.T.S. directly at ext. 339 for printouts. Elementary: request copy of class list from Office Manager and update at least weekly. 7. Health Records: In September check all Health Records against class list and pull any that are not listed on it - double check with Office Manager/Registrar. While checking Health Records, check also for immunizations and waivers. Flag records as needed and add name and information to Immunization Worksheet (PG VI-16), (see 2.4.). Update any Health Records that haven't been updated (new grade level & school year) and file in proper drawer. 1 see refers to this document Rev. 08/09/2013 I - 27

34 8. Pupil Health Office Visit Card: Check all cards against current class list, discard old cards after checking with your Nurse! Ongoing Procedures 1. Regular Office Traffic: For any student who comes to the Health Office keep a Pupil Health Office Visit Card (PG I-58) and record all information re procedures, phone calls, etc., on it. Also sign student in and out on Daily Health Office Log (PG I-30). In case of an injury, always fill out an Injury Report [PG II-30]) and make every effort to contact parent/guardian. In case of a fight have student fill out an Incident Report and Injury Report as needed and refer him/her to the Dean/Principal after contacting parent/guardian. 2. Transfer Students: Update information on Health Record (school name & year, grade level in pencil) File RI inside Pull Pupil Health Office Visit card if inside (usually only 7th or 8th graders) Check immunizations - flag if necessary (PG IV, A-G) (see 2.4.) Check for positive TB test follow-up (PG IV, I) (see 2.4.) Check for CSIR card (PG IV, G-17) and fill one out if needed (see 2.3.) File in filing cabinet 3. New Students: Check all newly registering students for immunizations and TB test. If they do not meet the requirements do not register until they do, unless they have homeless status (NCLB)! If they are up to date but need further immunizations later, flag record and write their name and info on the immunization worksheet (see 2.4.). Check for TB test: go by current information. Type new Health Record (PG I, J-57). Type new blue CSIR (California School Immunization Record) cards and record immunizations, sign and date it. On Health Record: use black pen to record immunization and family information as needed (Repro pen preferable, order from Warehouse). A. Pencil in address, school info, telephone number, immunization due dates if additional ones are needed. B. Flag as indicated (PG I-62) C. If health problem present, add name to Liability list (PG I-37). D. Fold all forms & CSIR card and place inside Health Record. E. Check with Nurse whether she wants call slips made up right away or later for Vision & Hearing test. F. Place on Nurse's desk for reviewing re liabilities etc. G. File when completed. Rev. 08/09/2013 I - 28

35 4. Immunizations and TB follow-up: Worksheets: write month/year in red on top left corner: use 1 or more for each month of the school year. File in chronological order in Immunization & TB file folder. Write name of student, grade level, immunizations or TB follow-up needed on appropriate worksheet under the month they are due. If immunization/s needed, mail out Inadequate Immunization Notice (PG VI-11) to parent/guardian or send home with student. After 2 weeks, follow up with phone call. Try to get parents to comply before sending out Immunization Exclusion Notice (PG VI-13). Exclude student if necessary and stay in touch with parent/guardian. Upon completion, make copy of new immunizations and place in record; update Health Record, CSIR card and on computer enter into student database. Enter student immunization including updates, TB and medical information into student database on computer throughout the year (Reminder Memo with computer printout will go out to you at the beginning of the 2 nd semester). TB follow-up: if student tested positive, refer for chest X-ray and request note from MD re results and possible preventive medicine (INH), note on record and file. Check immunization worksheets each week and work on them as needed. 5. CHDP: Work on CHDPs for 1 st graders continuously from September-December! Exclude students no later than 90 days after entering school if out of compliance. In spring, work on CHDPs for Kindergartners. Follow guidelines set out in Procedure Guide, Section V. 6. In October: request address labels for all grades sorted by last name from your Data Control Clerk. or I.T.S. directly (see 1.6.). Label Pupil Health Office Visit cards for new students and continuing students as they come to the Health Office (Middle & High). 7. In Fall and in Spring: check all Health Records against class list. Pull out any extra Health Records and check with Registrar/Records re status. Make a list of students without Health Records, check whether you have RIs. If no RI, check with Registrar re no-shows. Check Rls every other month against class list and Health Records, discard no-shows. If student here, but no Health Record in Cume try to get information from Records at ext If not found, check with Nurse re contacting parents for missing medical and immunization information and type a new Health Record complete with CSIR card (type Duplicate Record in upper left corner of Health Record). Type a CSIR card for any Health Records lacking one. Height & weight screening (Elementary): measure in fall and spring and record on Health Record as directed by Nurse. 8. Withdrawing students: Sign withdrawal form and sign student out in Health Office Manual, file Pupil Health Office Visit card inside Health Record and pass on to Registrar/Records. Rev. 08/09/2013 I - 29

36 9. When making any copies from old or new forms always save one copy and file in a manila folder labeled "Masters" to use for future copying. If you need a new form send a draft to Health Programs; all forms must be approved by the Director! 10. File incoming papers and records daily. 11. Vision and hearing screening results & scoliosis test: transcribe from class list per Nurse's request as directed by Nurse. 13. Ordering Supplies: Check inventory (PG I-63) and place orders 2-4 times per year or as needed. Order start-up supplies for the following school year in April of current school year and use up remaining budget. To find out budget status, check with Nurse/Office Manager or call Ed. Center and request information from Accounting Department (current budget info is sent to Principal/Office Manager every 2 weeks). End of School Year Procedures 1. Make copies of updated Liability list and send to all Middle/High Schools in District. 2. In June: update all Health Records with next school year and grade level information and file in next year's grade level if the transferring student s Health Records have been passed on to the Office Manager/Registrar. If not, do this at the start of the new school year. 3. File Medication Authorization forms inside Health Records and file any other relevant papers. 4. Pull all Pupil Health Office Visit cards from students transferring to secondary schools and file inside Health Records. 5. Check with Office Manager/Registrar and pull all transferring students Health Records when ready. 6. Make copies of all forms and registration packets as needed to start new school year. Annual Reports Immunization Assessment of Kindergarten Students (PG V-8): due around October 9 th Mandatory TB Report (PG VI-26): due around November 15 th CHDP Report (PG V-8): due around December 21 st Rev. 08/09/2013 I - 30

37 General Guidelines Read the Procedure Guide, any First Aid Guidelines Manual and Workbooks Check with Nurse and other Health Clerks and get a Buddy Health Clerk if you are new Amend and update this manual as needed for your site Learn as you go along! Notes: Rev. 08/09/2013 I - 31

38 Report of Performance for Probationary Classified Employees available at: Rev. 08/09/2013 I - 32

39 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS TO: FROM: SUBJECT: Ann Rector, Coordinator of Health Programs Health Clerk Evaluation Input EMPLOYEE: SCHOOL: DATE: Please indicate below your assessment of this employee. 1. Relates well to students. Excels Above Average Satisfactory Needs Improvement Unsatisfactory 2. Communicates easily with parents. 3. Demonstrates integrity and loyalty to nurse, health programs, and school. 4. Keeps scheduled time commitments and demonstrates conscientious attitude. 5. Knows and stays within limitations of her role. COMMENTS: Principal Rev. 08/09/2013 I - 35

40 SAMPLE ONLY UPDATED ANNUALLY PASADENA UNIFIED SCHOOL DISTRICT Health Programs MEMORANDUM TO: All Health Clerks DATE: September, 2008 FROM: SUBJECT: Ann Rector Student Immunizations & Medical Conditions Enclosed is a current printout for your school of all PK, Kindergarten and new students in grades 1-12 whose immunizations and medical conditions are not yet on the computer. Also enclosed is an updated copy of the ICD-9 Medical Codes for Students list dated 3/15/2000. The project of entering student s immunizations and any known health conditions into the computer is ongoing and needs to be completed before the end of the current school year. Please remember to update the student database any time you receive proof of additional immunizations/booster shots given. If you have any questions about using or accessing Aeries, please contact the ITS Help Desk at (626) Ext For general questions, please call (626) extension Thank you! Rev. 08/09/2013 I - 36

41 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS ICD-9 Medi-Cal Codes for students Health Concern ICD 9 CM Code Acne (pustular)(vulgaris) Allergy, unspecified Allergy to food (any) (ingested) Alopecia Anaphylactic shock/reaction to eggs Anaphylactic shock/reaction to food Anaphylactic shock/reaction to milk products Anaphylactic shock/reaction to peanuts Anemia unspecified Arthritis, juvenile Asthma, unspecified Autism, infantile Bee Sting Allergy Bell s Palsy, paralysis Bladder Disorder, unspecified Blood Disorder/Blood Forming Organs Disorder Cerebral Palsy, infantile, unspecified Color Blindness Colostomy status V443 Conjunctivitis, unspecified Conjunctivitis chronic Cystic Fibrosis Deficiency Vitamin D with rickets 2680 Dental Caries Depression Developmental Delay Diabetes Melitus Disorder, bipolar (unspecified) Disorder, conduct Disorder, depressive Disorder, eating unspecified Disorder, gastrointestinal Disorder, menstrual Disorder, oppositional, childhood & adolescence Down s syndrome Eczema Epilepsy, unspecified Examination, eye V 720 Gastritis Graves disease (other Specified disorders of thyroid) Headache, migraine Headache, tension Hearing Loss, conductive Heart Disease/Defect, congenital Hernia, diaphragmatic Hydrocephalus, obstructive Hydrocephalus, congenital Hyperactive/A.D.D Hypoglycemia, diabetic Impetigo Infection Wound, post-operative Murmur (cardiac)(heart) Muscular Dystrophy (congenital, hereditary) Myalgia Nervous Disorder/Anxiety Neurological Disease, unspecified Nosebleeds Rev. 08/09/2013 I - 37

42 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS ICD-9 Medi-Cal Codes for students Obesity Orthodontics V 58.5 Osgood-Schlatter Otitis Media Pain, stomach (dyspepsia, indigestion) Paralysis Reaction to Aspirin Reaction to Penicillin Redness, eye Refusal of treatment, because of, due to patient s decision Refusal of treatment, because of, due to reason of conscience or religion (i.e. Rheumatic blood transfusion Fever etc.) Rhinitis allergic Scarlet Fever Scoliosis Seizure Disorder Seizures, febrile Severe Menstrual Cramps Short stature, constitutional Sickle Cell Anemia Sinus Allergy, sinusitis Sinusitis Skin Allergy, skin reaction Slipped epiphysis (uspecified osteochondropathy) Speech Defect (Developmental speech or language disorder) Spina Bifida Sty, stye Tinea capitis Tinea corporis Tiredness Transplant bone marrow V Vision Problem Rev. 08/09/2013 I - 38

43 GENERAL PROCEDURES FOR SCHOOL PERSONNEL Secretarial Responsibility to Health Office 1. Notify health clerk or nurse of parent-reported illness that may be communicable. For example: Chicken pox Conjunctivitis Fifth Disease Hepatitis Impetigo, Ringworm or Scabies Measles or Mumps Strep infections or Scarlet Fever Tuberculosis 2. Notify nurse of any health problem causing a child to miss more than a week of school or chronic absences caused by any illness. 3. Pediculosis - If Health Office is not available, call parent and exclude child. Leave a note for the health office to follow up. 4. If Health Office staff is not available, the office staff can consult with the school nurse on call or the Ed Center Health Clinic. Maintain Communicable Disease Log Book 1. Date contacted/reported (this is what Public Health wants) 2. Student 3. Disease 4. Date Resolved 5. Physician Clearance Rev. 08/09/2013 I - 39

44 Health Office Daily Log for (month/day/year) at School PLEASE PRINT DATE NAME TIME IN GRD TEACHER REASON FOR VISIT TEMP DISPOSITION TIME OUT INIT Rev. 06/17/2013 I - 40

45 I. GENERAL PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS MONTHLY REPORT a. Students seen in Health Office: This should reflect the students logged into office daily log. b. Students with Medications in Health Office: The number of students with medications at school. II. SCREENING a. Vision: Include all students you screen for vision. b. Hearing: Include all students you screen for hearing. c. Scoliosis: Include all students you screen for scoliosis. d. Color Vision: Include all students you screen for color vision. e. Dental: Include all students you screen for dental. f. Lice: Include all students you screen for head lice. Count positive cases under communicable disease. g. Other: Include any other screening you do (substance abuse screening, immunization screening as part of registration, TB screening as a result of a positive case at your school site). III. CHILD SAFETY a. Emergency/Crisis Situations: Include any 911 calls, psychiatric hotline calls, etc. b. Injury Reports Filed: Number of injury reports completed. c. Child Abuse Reports Filed: Number of cases filed by health office. IV. SPECIAL EDUCATION a. IEP Evaluations: Number of students evaluated as part of an IEP (initial, triennial, annual, and addendum). b. IEP Meetings: Number of meetings the nurse attended. c. SST Evaluations: Number of students evaluated for SST. d. SST Meetings: Number of SST meetings attended by nurse. V. COMMUNICABLE DISEASE CONTROL: a. Chickenpox Cases: Diagnosed cases. If suspected put under screened. b. Conjunctivitis Cases: Diagnosed cases. If suspected put under screened. c. Head Lice Cases: Diagnosed cases. Log students you screen under Section II. Screening. Rev. 08/09/2013 I - 41

46 d. Positive PPD Cases: Diagnosed cases. e. Ringworm Cases: Diagnosed cases. f. Other: g. Other: h. Exclusions for communicable disease: Number of students excluded by health office due to suspected communicable disease. VI. HEALTH EDUCATION a. Parent Conference/Education, Phone: Log in number of phone calls made/received to parents. b. Parent Conference/Education, In person: Log encounters with parents in person. c. Teacher Conference: Log any instances where you discussed health-related concerns with a teacher regarding his/her student. d. Classroom Presentations: Any educational presentations you deliver to students. For example, hand-washing class, family life education, etc. e. Staff In-service: Any educational in-services you have given to staff. Do not include staff meetings you attend but do not present any information. VII. HEALTH REFERRALS a. Young & Healthy Referrals: Number of students referred to Y&H. b. Vision Referrals: Number of students referred for vision f/u. c. Hearing Referrals: Number of students referred for hearing f/u. d. Dental Referrals: Number of students referred to a dentist for f/u. e. Impact Referrals: Number of students referred to Impact. f. Mental Health Referrals: Number of students referred for mental health (whether it is at school site or off-site). g. Referral for Medical Care: Number of students you refer to follow-up medical care. VIII. HEALTH CARE DELIVERED a. Asthma Care: Actual number of times students came in for asthma management (whether it was an assessment of peak flow, PO2 reading, administering MDI or administering nebulizer). b. Diabetes Care: Actual number of times students came in for diabetes management (blood glucose checks, insulin administration, pump care, etc.). c. Seizure Care: Actual number of times health office assisted with seizure care (timing, recording seizures, administering medications such as Diastat, etc.). Rev. 08/09/2013 I - 42

47 d. Medications Administered: Actual number of times medications were administered for reasons other than asthma, diabetes, seizures, in health office. For example, ADHD meds, headache meds, creams, etc.). e. TB Tests Administered: Number of TB tests given to parent volunteers. f. Immunizations Administered: Include flu vaccines as well as other immunizations you give. g. Gastrostomy Tube Feeding: Performed or observed by nurse. h. I&O Catheterization: Performed or observed by nurse. i. Tracheotomy Care: Performed or observed by nurse. j. Health Care to Staff: Count all encounters where you deliver health care to staff members (e.g. Blood pressure checks, first aid, etc.). k. CHDP Physicals (Nurse Practitioners Only): Count all CHDP physicals performed by nurse practitioner. l. Other: Any other health care delivered to student not captured above. Rev. 08/09/2013 I - 43

48 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS FIRST SEMESTER MONTHLY REPORT Year Nurse School I. GENERAL c. Students seen in Health Office: d. Students with Medications in Health Office: h. Vision: i. Hearing: j. Scoliosis: k. Color Vision: l. Dental: m. Lice: II. SCREENING n. Other: III. CHILD SAFETY d. Emergency/Crisis Situations: e. Injury Reports Filed: f. Child Abuse Reports Filed: IV. SPECIAL EDUCATION e. IEP Evaluations: f. IEP Meetings: g. SST Evaluations: h. SST Meetings: V. COMMUNICABLE DISEASE CONTROL: i. Chickenpox Cases: j. Conjunctivitis Cases: k. Head Lice Cases: l. Positive PPD Cases: m. Ringworm Cases: n. Other: o. Other: SEP OCT NOV DEC JAN Rev. 08/09/2013 I - 44

49 p. Exclusions for communicable disease: VI. HEALTH EDUCATION f. Parent Conference/Education, Phone: g. Parent Conference/Education, In person: h. Teacher Conference: i. Classroom Presentations: a. Grade Level: b. Topic: j. Staff In-service: VII. HEALTH REFERRALS h. Young & Healthy Referrals: i. Vision Referrals: j. Hearing Referrals: k. Dental Referrals: l. Impact Referrals: m. Mental Health Referrals: n. Referral for Medical Care: VIII. HEALTH CARE DELIVERED m. Asthma Care: n. Diabetes Care: o. Seizure Care: p. Medications Administered: q. TB Tests Administered: r. Immunizations Administered: s. Gastrostomy Tube Feeding: t. I&O Catheterization: u. Tracheotomy Care: v. Health Care to Staff: w. CHDP Physicals (Nurse Practitioners Only): x. Other: SEP OCT NOV DEC JAN Rev. 08/09/2013 I - 45

50 PASADENA UNIFIED SCHOOL DISTRICT SECOND HEALTH PROGRAMS MONTHLY REPORTS Year Nurse School FEB MAR APR MAY JUN I. GENERAL e. Students seen in Health Office: f. Students with Medications in Health Office: II. SCREENING o. Vision: p. Hearing: q. Scoliosis: r. Color Vision: s. Dental: t. Lice: u. Other: III. CHILD SAFETY g. Emergency/Crisis Situations: h. Injury Reports Filed: i. Child Abuse Reports Filed: IV. SPECIAL EDUCATION i. IEP Evaluations: j. IEP Meetings: k. SST Evaluations: l. SST Meetings: V. COMMUNICABLE DISEASE CONTROL: q. Chickenpox Cases: r. Conjunctivitis Cases: s. Head Lice Cases: t. Positive PPD Cases: u. Ringworm Cases: v. Other: w. Other: x. Exclusions for communicable disease: Rev. 08/09/2013 I - 46

51 VI. HEALTH EDUCATION k. Parent Conference/Education, Phone: l. Parent Conference/Education, In person: m. Teacher Conference: n. Classroom Presentations: a. Grade Level: b. Topic: o. Staff In-service: VII. HEALTH REFERRALS o. Young & Healthy Referrals: p. Vision Referrals: q. Hearing Referrals: r. Dental Referrals: s. Impact Referrals: t. Mental Health Referrals: u. Referral for Medical Care: VIII. HEALTH CARE DELIVERED y. Asthma Care: z. Diabetes Care: aa. Seizure Care: bb. Medications Administered: cc. TB Tests Administered: dd. Immunizations Administered: ee. Gastrostomy Tube Feeding: ff. I&O Catheterization: gg. Tracheotomy Care: hh. Health Care to Staff: ii. CHDP Physicals (Nurse Practitioners Only): jj. Other: FEB MAR APR MAY JUN Rev. 08/09/2013 I - 47

52 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS ON CAST/CRUTCHES/ WHEELCHAIR SCHOOL YEAR NAME GRADE FROM (DATE) TO (DATE) TYPE DR. S NOTE Rev. 08/09/2013 I - 48

53 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS WITH COMMUNICABLE DISEASE SCHOOL YEAR DATE NAME GRADE DISEASE HEALT H DEPT. ONSET DATE CLEARANCE DATE Rev. 08/09/2013 I - 49

54 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS ON MEDICATION SCHOOL YEAR NAME GRADE MEDICATION TIME TO BE GIVEN Rev. 08/09/2013 I - 50

55 School PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS WITH SPECIAL HEALTH CONCERNS SCHOOL YEAR Nurse STUDENT Last Name First Name I.D. Number Birthdate Special Health Problems Grade Teacher Rev. 08/09/2013 I - 51

56 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS REFERRED FOR COUNSELING SCHOOL YEAR NAME GRADE DATE AGENCY/IN OFFICE Rev. 08/09/2013 I - 52

57 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS REFERRED FOR HEARING SCHOOL YEAR NAME DATE I.D.# GRADE RESULTS RETEST REFER FOLLOW-UP Rev. 08/09/2013 I - 53

58 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS REFERRED FOR MEDICAL CARE SCHOOL YEAR NAME GRADE DATE PROBLEM FOLLOW-UP Rev. 08/09/2013 I - 54

59 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS REFERRED FOR SST MEETING SCHOOL YEAR NAME GRADE DATE ASSESSMENT DONE SST MTG. DATE Rev. 08/09/2013 I - 55

60 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS REFERRED FOR VISION SCHOOL YEAR NAME DATE I.D.# GRADE RESULTS REFERRAL SENT WITH STU/MAILED FOLLOW-UP Rev. 08/09/2013 I - 56

61 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS REFERRED TO YOUNG AND HEALTHY SCHOOL YEAR NAME DATE GRADE PROBLEM REFERRED TO APPT. FORM GIVEN Rev. 08/09/2013 I - 57

62 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS REFERRAL FOR HEALTH CARE Child s Name: DOB: Grade: Date: Dear Parents: Your child needs follow-up care for 1. Your child may return on, ONLY IF WELL FOR 24 HOURS. 2. Your child must be cleared by the school nurse/health assistant before returning. 3. Please have your doctor/dentist complete the lower portion of this form. 4. Please sign below so the doctor/dentist can supply needed information. Parent Signature: Date: TO BE COMPLETED BY HEALTH CARE PROVIDER/DENTIST Date examined by Provider/Dentist: Provider/Dentist Signature: Phone: Diagnosis and/or special instructions: Treatment plan: PLEASE RETURN FORM TO: School Nurse: School: Address: Telephone: Rev. 08/09/2013 I - 58

63 DISTRITO ESCOLAR UNIFICADO DE PASADENA PROGRAMAS DE SALUD RECOMENDACIÓN PARA CUIDADO DE SALUD Nombre del Niño: FDN:. Grado: Fecha: Estimados Padres: Su niño necesita continuar atendiéndose el/la 1. Su niño puede regresar el estad, SÓLO SI NO HA ESTADO ENFERMO POR 24 HORAS. 2. La enfermera de la escuela/asistente de salud debe ver a su niño antes de que regrese a la escuela. 3. Por favor pídale a su médico/dentista que complete la porción de abajo de esta forma. 4. Por favor firme abajo para que el médico/dentista pueda dar la información que se necesita. Firma del Padre/Tutor: Fecha PARA QUE LA COMPLETE EL PROVEEDOR DE SERVICIOS MÉDICOS/DENTALES Fecha en que fue examinado por el Proveedor/Dentista: Firma del Proveedor/Dentista: Diagnósis y/o instrucciones especiales: Teléfono Plan del Tratamiento: POR FAVOR REGRESE LA FORMA A: Enfermera de la Escuela: Escuela: Domicilio: No. de Teléfono: Rev. 08/09/2013 I - 59

64 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS REQUEST FOR FOLLOW-UP Student s Name School Date of Birth Grade Dear Parent/Guardian: Please take this form to your health care provider and return his/her report to school as soon as possible. Sincerely, School Nurse Date TO BE COMPLETED BY HEALTH CARE PROVIDER Date Examined: Provider s Address Provider s Signature Assessment: Provider s Name Phone: Fax: Treatment Plan: PLEASE RETURN THIS FORM TO: Name: School: Address: Rev. 08/09/2013 I - 60

65 DISTRITO ESCOLAR UNIFICADO DE PASADENA PROGRAMAS DE SALUD PETICICIÓN PARA CONTINUACIÓN DE LOS SERVICIOS Nombre del Estudiante: Escuela: Estimados Padre/Tutor: Fecha de Nacimiento: Por favor lleve esta forma a la persona que le da servicios de salud y regrese su reporte a la escuela tan pronto como le sea posible. Respetuosamente, Enfermera de la Escuela Fecha PARA QUE LO COMPLETE LA PERSONA QUE PROVEA EL CUIDADO DE SALUD Fecha del Examen: Nombre de la Persona que lo Hizo: Domicilio de la Persona que Provee el Cuidado de Salud: Firma de la Persona que Provee el Cuidado De Salud: Tel: Fax: Evaluación: Plan para Tratamiento: POR FAVOR REGRESE ESTA FORMA A: Nombre: Escuela: Domicilio: Rev. 08/09/2013 I - 61

66 Rev. 08/09/2013 I - 62

LOS ANGELES UNIFIED SCHOOL DISTRICT Policy Bulletin

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