confidentiality, health records, and duty to report cindy greenberg osah clinical nurse consultant...

Confidentiality, Health Records, and Duty to Report

Cindy Greenberg OSAH Clinical Nurse Consultant

NM Department of Health Office of School & Adolescent Health

Cynthia.greenberg@state.nm.us 505-222-8680

Cynthia Greenberg, RN, BSN, MSN, NCSN

Objectives

1. Describe guidelines for maintaining the confidentiality of student health information.

2. Identify indicators of child abuse/neglect and the duty to report.

What is confidential information?All health information should be considered confidential including verbal, written, and electronic health information.

Confidentiality – Verbal Communication

Verbal Information

Foundational to our health is safety.

Healing and health happen together.

“Sacred information”

Anything a student says to the school health assistant or the nurse is kept confidential.

Few exceptions

Exceptions

Possibility the student is or will:

Harm self

Harm others

Is being harmed or abused

Confidentiality with Written Information – Charting & Records

Written Information Write so we can all read it – only use agreed

upon abbreviations, no texting language Use a pen – black ink preferable

Use standard medical abbreviations

Date and sign each entry note

Report what you observe -avoid judgments and opinions

To correct a mistake:- Draw a line through error and initial. - Do not erase or use white out

“Just the facts, Ma’am”

Legally speaking: If it isn’t documented, it was not done!!!!

Student Health Screenings

Student Health Information:

•Provided by the parent or guardian

• Includes all pertinent health and family history

•Obtained when the student first registers with a school district and is updated each year

Health information is:

Student Health Record/File• Medication order/permission form

• Emergency information

• Original accident report

• Screening, referrals, and follow-up information

• Screening for Special Ed.

• Medical /Health history/ IHPs

• PE or other class restrictions or exemptions

• Health evaluations from outside medical providers &

agencies

• Confidential release forms

• Immunization record or exemptions

• Must be stored safely and securely.

How long are schools required to keep student health records?

[NMAC 1.20.2.101] The student health record includes but is not limited to health history, immunization record, results and recommendations from medical examinations, medical orders, screenings, treatments, parent or guardian referral record, teacher comments, etc.

Must be retained: 10 years after date of last entry or until student attains age 19, whichever is longer.

Child AbuseReporting

Types of Abuse

1. Physical

2. Emotional

3. Sexual

4. Neglect

Child Abuse Reporting

The NM Children’s Code 32A-4-3 states:

Any person who SUSPECTS or HAS KNOWLEDGE

that a child is being abused or neglected is

mandated to report to:

• Local Law Enforcement

• Child Protective Services or

• Tribal Law Enforcement

NM Statewide Central Intake

1-800-797-3260From a cell phone: Text #SAFE (#7233) or Call 1-855-333-SAFE to report suspected child

abuse or neglect

Albuquerque: 841-6100

Required Information:

•Child’s name, age, & date of birth

•Current location

•Parent/guardian name & address

•Name of siblings also at risk

•Name of alleged perpetrator and location

•Description of concerns

Stories and Questions:

REMEMBER:

Do not hesitate to report because of lack of

information—if you suspect abuse, the

information you have is valuable!