One of the most challenging responsibilities of school nurses is managing the many types of student health records, both paper and electronic. They include documents such as immunization records, screening records, progress notes, physician orders, physical examination records, medication and treatment logs, individualized health care plans, emergency health care plans, third party medical records, consent forms, Medicaid and other insurance billing forms, and flow charts.
School health records provide the mechanism for a school nurse to communicate information to students, families, the school multidisciplinary team, emergency personnel, other health care providers, and school nurse substitutes. Data from school health records can be used to show evidence of student health problems that should be addressed. Data can also be used for evaluation of school health programs, quality assurance, and evaluation of program outcomes. School health records are transferred to new school sites when a student progresses to other buildings within a district or moves to another district.
It is important for school districts to have policies and procedures regarding the types, maintenance, protection, access, retention, destruction, and confidentiality of student health records. State laws and regulations may dictate these policies and procedures (Harrigan, 2002).
As society and the health care system are moving from paper to electronic technology, so too is the school health office. Technology currently in use to receive and transmit student health information includes:
Cellular and cordless telephones
E-mail via computer
Facsimile machine (fax)
Personal digital assistant (PDA)
The following areas are considered when examining a school health records system:
- The foundation and rationale for any school health records system should be based on who needs the information, what information they need for the benefit of the student, and who has the expertise to interpret the records (National Association of State School Nurse Consultants, 2000; Schwab & Gelfman, 2001).
- School health records are maintained for purposes of communication, legal evidence, research, education, quality assurance monitoring, statistics, accrediting/licensing, and reimbursement (Schwab, Panettieri, & Bergren, 1998).
- In keeping with medical record requirements, school health records are cumulative and chronological, and errors are not changed, rather recorded on the appropriate date (Schwab & Gelfman, 2001).
- Management of student health records includes their generation, maintenance, protection, disclosure, and destruction. Privacy, confidentiality, and consent are related to record management. (NASN, 2002).
- Paper records are generally kept in locked files. Some school staff will need immediate access to some health information, such as that in emergency care plans, 504 plans, IEPs, and written instructions for care providers (Schwab & Gelfman, 2001).
- Laws governing school health records include the Federal Family Education Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA) as well as individual state laws (Bergren, 2001c).
- Computer databases that provide comprehensive student health records and health office logs are available. These are enhanced by nurses using personal computers linked to a network of computers in a building or district. Some school nurses serving multiple buildings use notebook computers to carry from school to school and connect to the network while in each building (Schwab & Gelfman, 2001).
- Fax machines are widely used for transmitting health information. In schools, fax machines streamline accessing such records as immunizations, parental permissions, doctor’s orders, clinic records, and pharmacy communications regarding medications (Bergren, 2001b).
- PDAs augment computers by sharing information with them. Some school nurses find PDAs useful for digital data collection and retrieval. Student health data is collected during screenings or accessed during emergencies on the school campus. Information is uploaded onto the school nurse’s computer at a later time (Suszka-Hildebrandt, 2001).
- E-mail has become a standard method of communicating in the school setting among staff in and outside of the school district. E-mail is self-documenting and can be retained in a paper or electronic health record at the time of the exchange, eliminating the need for additional notation. The original message is preserved into a file by downloading (Bergren, 2001a).
Health information in either paper or electronic form must be confidential, secure, accessible only by authorized staff, and protected from loss or destruction (Bergren, 2001b). Information transmitted via the newer technologies is different from paper records in that it can be fairly easily misdirected, intercepted, rerouted, and read by recipients for whom it is not intended (Bergren, 2001a). Because of this, new methods of security must be undertaken.
ROLE OF THE SCHOOL NURSE
School nurses need to address the many issues surrounding student health records in the school health office. Ensuring the security and privacy of both electronic and paper records is of utmost importance. In addition, school nurses must know the relevant federal and state laws, regulations, and guidelines about school health record maintenance, protection, disclosure, and destruction. In addressing these issues, school nurses should evaluate school district policies and procedures, initiate changes if indicated, and educate staff, students, and parents (NASN, 2002).
Electronic records and their transmission pose potential problems that school nurses must address. Special provisions must be established to protect electronic health records and student privacy in the school district. The specific method of storing student health data determines the particular opportunities for abuse of its integrity, so school nurses should be involved on the school district technology team to give input on the need for privacy. Additionally, school nurses should be able to describe the security measures taken by the school district to protect student confidentiality (Schwab & Gelfman, 2001).
Computers have streamlined record keeping for many school nurses. Along with the convenience comes the need to protect both on-screen and stored information. The use of secure passwords, programs to thwart hackers, and screen savers, as well as several areas of access for the student health data base and a policy of never leaving the computer unattended when student health data is accessible or viewable, is necessary for security. Computer software should have over-write protection and multi-level access if multiple health office employees will be entering data (Schwab & Gelfman, 2001).
Informed consent should be obtained before using e-mail for transmissions from the health office. Consent forms should describe the school district security and the expected response time, and explain that transmissions will be placed in the student’s health file. The school nurse should assist the school district in establishing a policy for the type of information that may be sent via e-mail. Messages with identifiable health information should be encrypted. Additional security measures regarding e-mail include precautions to prevent misdirected e-mail; password-protected screen savers; never forwarding messages without permission of parent, health provider, or student; and prohibiting sharing of health office
e-mail accounts or passwords with anyone. A confidentiality statement should be written on all e-mail messages involving students (Bergren, 2001a).
When faxing, school nurses should include a cover page that states the confidentiality and limited use of student health information. To protect student confidentiality when faxing documents, the school nurse should fax only when mail will not suffice, transmit only requested information, keep faxes short, and obtain proper authorization. The fax machine should be located in a secure area of the school where it can be monitored by authorized staff. School nurses need to know what their individual state laws specify regarding whether a fax document can be used instead of the original signed paper document for doctors orders and prescriptions (Bergren, 2001b).
School nurses utilizing technology in the health office need to emphasize to their school administrators the importance of keeping student health information secure and private. The school technology team should provide assistance in explaining what is needed and how it can be implemented. Funding for security measures might be obtained through the school parent organization or a community service organization.
Bergren, M.D. (2001a). The facts about e-mail. Journal of School Nursing. 17(5). 274-277.
Bergren, M.D. (2001b). The facts about faxing. Journal of School Nursing. 17(4). 210-212.
Bergren, M.D. (2001c). HIPAA hoopla: Privacy and security of identifiable health information. Journal of School Nursing. 17(6). 336-341.
Harrigan, J.F. (2002). Overview of school health services. Scarborough, ME and Castle Rock, CO. National Association of School Nurses.
National Association of School Nurses. (2002). Issue brief: Privacy standards for student health records. Scarborough, ME and Castle Rock, CO: Author. Available at http://www.nasn.org/Default.aspx?tabid=277
National Association of State School Nurse Consultants. (2000). Position statement: Confidentiality of health information in school. Available at: http:www.nassnc.org
Schwab, N.C. & Gelfman, M.H.B. (Eds.). (2001). Legal issues in school health services: A resource for school administrators, school attorneys, school nurses. North Branch, MN: Sunrise River Press.
Schwab, N.C., Panettieri, M.J., & Bergren, M.D. (1998). Guidelines for school nursing documentation: Standards, issues, and models (2nd ed.). Scarborough, ME and Castle Rock, CO. National Association of School Nurses.
Suszka-Hildebrandt, S. (2001). Handheld computing: The next technology frontier for school nurses. Journal of School Nursing. 17(2). 98-102.