The Student School Health Record

School health personnel should participate in the development of both the health record and the record system procedures. All school health records should be considered as part of the district record system and must be retained in the school district for a legally required period of time.

A student health record containing information which is accurate, pertinent, objective and useful constitutes a method to serve the student's health and educational interests.

The task of gathering, organizing and maintaining health information about all students is a demanding one. An orderly and efficient procedure must be established as part of the district's program of student record management. Discretion and good judgment on the part of the professional staff must be exercised.

What Is a Student Health Record?

T he term student health record means those records maintained by the school for each student which provides relevant information about the physical, developmental, intellectual, personal, social and environmental factors which affect the student's health and education.

Such information can be useful to school personnel in helping to make decisions about the individual student's school program.

LEGAL CONSIDERATIONS of Student Health Records

There are legal and regulatory considerations regarding student records and their use.

From a legal standpoint, any record relating to a student which is used by school district personnel constitutes a student record. It includes formal records which have been developed for specific purposes. It also includes informal records or notes, if such notations are placed in a student's folder or record.

Any record prepared by an outside agency, and transmitted to the school, also becomes part of the student record if it is added to the student's folder and used by school personnel.

PRIMARY, CUMULATIVE

Student Health Records

A cumulative health record is maintained for each student during their school years. It includes a place to record information regarding

-- health history,

-- immunization procedures,

-- medical examinations,

-- screening procedures,

-- medical recommendations,

-- medical referrals,

-- teacher observations,

-- a problem list,

-- progress notes,

-- flowsheets, etc.

SUPPLEMENTARY

Student Health Records

The complete student health record frequently includes supplementary records such as:

-- health history reports from parents,

-- reports of medical examinations by the family physician,

-- dental examination reports,

-- reports from vision and hearing specialists, and

-- medical requests for program adaptation of various kinds.

The cumulative health record and all supplemental records included in the student's folder thus become part of the total health record of each student.

PARENTS and THIRD PARTY Agencies

School records, including health records, are legally listed as confidential records. The privileged or confidential nature of the record excludes third parties from the record.

The privileged or confidential nature of the record does not exclude the parents.

However, the school has an obligation to provide professional interpretation and advice whenever a student health record is made available to parents.

Furthermore, it should be kept in mind that health record information may be shared with personnel of cooperating agencies only with the consent of the parent or guardian.

The United States Family Educational Rights and Privacy Act of 1974 (FERPA) has been extensively amended by Congress. The purpose of the Act is to ensure the availability of student records to parents of students under 18 years of age, to students and former students over 18 years of age, and to ensure confidentiality of such records with respect to third parties.

SCHOOL STAFF and CLASSROOM TEACHERS

School Nursing personnel have the responsibility to share with staff and classroom teachers information about specific student health conditions which can affect their educational progress.

This does not mean that the record itself is shared; the non-school health staff should not have access to the entire student health record.

When it is necessary to share information for the educational needs of the student, school nursing personnel should interpret the findings to assure that there is no misunderstanding regarding the condition or the professional recommendations.

Any adjunct health information, such as lists of students with health conditions, should be treated in a confidential manner. They should be labeled "Confidential" and should not be posted or distributed indiscriminately.

Sensitive Information

Information recorded must be pertinent, factual and objective. There is no place on a health record for rumor, speculation, opinion, assumption or unsubstantiated observation. Moreover, factual information which is not relevant to the student's education, and which could adversely affect their reputation or school progress, should be omitted.

Sensitive health problems such as pregnancy, emotional problems, social-family problems (child abuse, substance abuse, sexual activity) need careful consideration as to whether or not such information should be included in the student's health record.

It is important to consider whether or not the recording of the information in the student's health record would be detrimental to the student now or in the future, whether or not the information has educational implications.

Separate and Confidential Professional Notes

If the decision is made not to include the information on the student's health record, it may be necessary to maintain separate and confidential professional notes in a separate and secure location for guiding the student through the provision of needed services. Such professional notes should be destroyed at the discretion of the professional when the information is no longer relevant to the services being provided.

Recording Standards

-- do not erase or use erasable pen -- do not use "white-out"

-- if an error is made in recording, cross out with a single black line and initial

-- use black ink

-- if abbreviations are used, they should be standard medical or dictionary abbreviations

Filing of Health Records
The method of filing health records is usually determined by the school student records system and, to some extent, by individual preference. There are advantages in maintaining a file folder for each student which will include the cumulative health record and all supplementary records and reports. Health records should be kept in locked files in the school health office to provide for accessibility and security.

Transfer of Health Records
Original student health records should not be transferred from the jurisdiction of the school district where they were initiated. When a child transfers to another school district, a transcript or photocopy of the original should be forwarded to the school district to which the student has transferred upon written request by that district and the parent. Nonpublic schools are considered "another school district" even though the health services may have been provided by the district from which the child has transferred. Copies of health records being sent should be marked "Confidential."

Disposition of Student Health Records
A procedure for disposition of school records has been established by school policy. School health personnel should consult the district clerk each year for the latest regulations regarding the disposition of health records and meet these criteria for disposition.

Material in this section developed from Wold, S., School Nursing: A Framework for Practice, (1981).