School Health Services Essentials

After a school or district evaluates their population and the health needs of their students through Health services Assessment Tool for Schools, there are several different models for the delivery of school health program services. Although school districts have some flexibility in this decision, Minnesota school health law requires all school districts with 1,000 students or more (including all early childhood programming) to hire a full time Licensed School Nurse. Schools with less than 1,000 students must hire appropriately to meet the needs of their students. More importantly than exact numbers, the law highlights the obligation to meet the needs of the students, which will vary greatly and requires a clear understanding of nursing licensure.

Types of Health Services Structures

• Hired directly by the school - the Licensed School Nurse is hired by the school district. The other employees, RNs, LPNs or UAPs that they supervise are also hired by the school district. It is important to note that a school district may not hire an LPN to work independently, supervision must be available.
• Contracted by the school - If the school or district elects not to hire their own employee, they may enter into a contract with an outside agency. This is often local public health but may also be another agency such as home health, local clinics, etc. that hire nurses with the appropriate licensure. The contract should clearly delineate the amount of time the nurse is in the school, what tasks are included in the contract, how will health services be provided if the hours do not cover the entire school day and what are the obligations of the agency outside the hours when the nurse is physically present. Each contract will have many other additional unique situations that should be closely considered by both parties prior to the start of each school year.
• Consulting agency - In an effort to meet the minimal standards, some schools elect to enter into a consultation agreement with an outside agency. Consultation and contracted nursing are very different in relation to nursing delegation and oversight and should be very carefully reviewed and understood before deciding on an approach. It is important to remember that regardless of what model the school chooses to staff their office, the school is ultimately responsible to meet the health needs of all of their students. Performing health care tasks with people working outside of their training and skill level poses a risk for the district, the staff member and most importantly, the students.
• School Based Health Centers (SBHC) - SBHCs are an excellent complement to school health services, although function differently and each have their own set of standards and requirements. SBHCs fulfill a separate need from that described in the Minnesota School Health Legislation.
• In school districts without Licensed School Nurses/Registered Nurses (LSNs/RNs) on staff, educational administrators working with school boards are responsible to set up a system through which medication administration policies are developed, acceptable LSN/RN/ licensed health care provider coverage for medication administration oversight via contract or other arrangements is found, people are assigned and trained, the procedures are done safely and consistently, and all necessary documentation is completed.
  Educational administrators are also responsible to find appropriate resources and medical expertise to address their students' medication administration needs. School administrators cannot legally fulfill the role of LSNs/RNs. Training for medication administration is beyond the role of education administrators. Districts with LSNs/RNs on staff or on contract will be the lead on developing school district policies and procedures which include medication program: supervision, delegation, assignment, administration, documentation, etc.

Types of Nurses and Staff in the Health Office

School districts often employ nurses with a variety of levels of licensure. It is important that the school districts and the employees have a very clear understanding of what the expectations and limitations of each role are so as to not practice outside of their licensure. The health office may include:

Licensed School Nurses: Professional nurses with licensure through the Board of Nursing and the Board of Teaching, who specialize in the area of school health. Licensed School Nurses have a bachelor's degree in nursing, a registered nurse license, a public health registration certificate, and a school nurse license. It is important to note that no one should be called, or call themselves a school nurse who does not hold all of these licenses. MN Administrative Rule 8710.6100

Public Health Nurses: Professional nurses who have a registered nurse license and have a public health nurse registration certificate can be contracted to provide school health services. MN Administrative Rule 6316

Registered Nurses: There is great variability in the training to be eligible to become a registered nurse. This may be an associate (2 year) or bachelor's (4 year) degree prepared nurse. However, population health is not included in the training for associate degree RNs and this should be considered when creating health services structure.

Licensed Practical Nurses: The Licensed Practical Nurse (LPN) is a distinct licensure from the Board of Nursing. The differences between the role of the LPN and RN are clearly delineated in the Nurse Practice Act. It is essential that both the LPN and the school district have a very clear understanding of the licensure when utilizing LPNs in the health office. There also needs to be a structure of supervision in place for an LPN.

Unlicensed Assistive Personnel: Also called a UAP, this is anyone who is providing health services in the school setting but does not have any type of healthcare license. Most often this is referring to the health assistant who is providing services in the office but it also includes any teachers, administrators or other school staff that provide health services under the direction of the registered nurse or other qualified health professional.

In this section you will find examples of policies and procedures as well as key elements for writing your own:

General Policy and Procedure Guidance

Schools need well-defined health policies and procedures. A policy is a guide for decision making within an organization that is a rule for action. Policies are typically developed and adopted by the local school board after being systematically reviewed by a team. A procedure is a sequence of steps that should be followed to implement policies or plans. Procedures are usually written by school administrators or expert program staff. Whereas policies are broad, procedures are specific and detailed. Policies and procedures should be dated when issued. Review and revision is recommended at least every two years.

Policies should be based on federal, state, local laws, or rules and regulations; on standards established by state agencies such as the Minnesota Department of Education, Minnesota Department of Health, the Board of Nursing, or the Board of Teaching; on standards set by professional organizations such as the American Nurses Association (ANA), National Association of School Nurses (NASN), American Academy of Pediatrics, American School Health Association, etc. Codes of ethical conduct for the various professions are also considered when developing policies.

A general rule in policy development is that local school policies must be consistent with federal and state laws and rules at a minimum but can be more specific than minimum requirements. For example, state law requires immunization of students but the local policy may define how that requirement will be met.

Procedures should clearly outline who can or will do the task, when the task will be completed, where it will take place, what steps are expected, how to manage uncertainties or problems, how it will be documented and any other information that is key to the safe and consistent completion.

Communication of Policies and Procedures

Each school district has a process for introducing and updating policies and procedures that should be reviewed before implementing a new policy and procedure manual. After development or revision and subsequent school board approval, health policies need to be communicated to parents/legal guardians, students, school health staff, and all other school personnel. In addition, a copy of the health policy and procedure manual should be available for review by any interested parent/legal guardian or student. Whenever possible, important new policies should be publicized by the local media.

Policy and Procedures Manual

Each school district should have a policy and procedure manual for school health services containing the relevant district and school specific information about how health services will be provided. Use of an online format with links to the appropriate resources allows for the resource to be kept up to date.

Just like health plans are unique to each student, policy and procedure manuals are unique to each school and district. The following are ideas, based on best practice, which may be considered.

Policy and Procedure Manual Table of Contents (PDF)

The common myth that school health offices are in place for "bandages and ice packs" could not be further from the truth. It is very important for all school staff and administration to understand all that happens in the health office.

It is no longer the top priority of the health office nurse to be used to obtain first-aid treatment, to rest under observation for illness, or to wait for a parent/legal guardian to take them home. Although, students still use the health office for these purposes, the functions have grown in conjunction with the ever-increasing responsibilities of school health services personnel. Just a few of these responsibilities include assisting students with chronic health conditions and ensuring inclusion in the school day, student emergency care planning, training, intervention, collaboration and communication with families, referrals, screenings, student and staff wellness interventions, infection control, student social and emotional issues, disease prevention, and much, much more.

Many health offices have enlisted unlicensed assistive personnel (UAPs) trained by and under the supervision of the Licensed School Nurse (LSN) or Registered Nurse (RN). The LSN/RN delegates specific nursing tasks to the unlicensed staff that allows them to provide first aid treatment, illness monitoring or uncomplicated nursing tasks for which they have been specifically trained and supervised to complete. Unless the office is staffed by a Licensed School Nurse all day, the space should be called the "Health Office" and not the "Nurse's Office" to avoid any inference that a nurse is providing care when in fact it may not be a nurse. Unlicensed staff need to clarify any time they are referred to as the nurse. They do not have that license or education and should work to correct the perception that they are. Minnesota has instated legislation to ensure schools take steps to clarify who is and is not licensed by the Board of Nursing when working in the schools. LPNs and RNs who do not have a School Nurse license from the Board of Teaching also need to clarify that they are a nurse in the school, not a School Nurse which has a different level of ongoing education.

Functions of a School Health Services Office

The school health services office serves multiple functions, therefore the space it is housed in should allow for carrying out these functions:

• A private conference space where the nurse, teacher, student, parent/legal guardian, or others can discuss specific health problems of individual students in privacy.
• A space for the care of students who become ill or are suspected of having a communicable disease, until they can be placed under their parent/legal guardian's care or returned to class.
• A place for provision of first aid and general health care (treatments and medications).
• Sinks and toilets to ensure consistent monitoring of ill students, proper access to handwashing facilities and water for students taking medications.
• A location where student health records are kept securely.
• A space that supports making health appraisals, where vision, hearing and other screening procedures are carried out; and immunizations are provided, etc.
• A resource center for health education and reference materials.
• An area to provide a program of expanded school primary care services, as determined by local school district needs.
• A place for those who require a rest period because of identified, ongoing health needs, different than that used for those who are contagious.
• A storage area for health supplies and equipment, and secured area for medications privacy and administration.
• A private space for the administration of medications and a locked space for storage of medication.

Basic Health Office Equipment and Supplies:

Here is a basic list of possible health office supplies (PDF)

The Minnesota Department of Health has partnered with the Hennepin County Medical Center to develop the Infectious Diseases in Childcare Settings and Schools Manual. This manual has clear guidance for a majority of infectious diseases that are seen in schools. The manual includes fact sheets about the condition, incubation period, and symptoms, how long students are typically contagious and how long they should stay out of school. This tool has been developed using the most up to do date best practices and it is highly recommended that schools follow utilize this resource.

Families should be provided with guidelines for when to keep their students home from school related to illness.

First Aid Guidelines

Medication Administration

School nurses are instrumental in ensuring both strong medication policy and the safe delivery of medications. Guidance for best practices can be found in the Minnesota Guidelines for Medication Administration in the Schools

Medical Cannabis at School

At this time, medical cannabis may not be administered on school property or be given by nurses who are not designated as the caregiver in the registry. Students who require medical cannabis in the school day need to make alternative arrangements with their registered care providers for off-site administration.

The Minnesota Department of Health Medical Cannabis home page has the most up to date information regarding the law, certification process and administration.

Immunizations

It is critical that all health services staff understand the immunization requirements. The most up to date immunization information can be found at the Minnesota Department of Health Immunizations page under School Health Professionals.

The Minnesota Immunization Law (statute 121A.15) outlines the requirements for immunizations in Minnesota. The most recent immunization requirements can be found in Minnesota Administrative Rules 4604.

School nurses play an essential role in ensuring that families have accurate information regarding immunizations. Critical conversations around immunization safety and vaccine preventable disease realities in the health office every day.

One key element of the immunization law is how and what is communicated to families regarding immunizations. When communicating about immunizations, schools must include a complete list of required immunizations and clear information regarding how to obtain medical or conscientious exemption. The most concise ways to do this is to include the Student Immunization Form in all communications with families regarding immunizations.

Health Office Immunization Essentials:

Who Needs Vaccines, When

Vaccine Information Sheets (VIS)

Minnesota Vaccines for Children Program (MNVFC) assists with providing low cost or free vaccines to all children in Minnesota.

Obtaining Immunization Information

Vaccines are so essential to the public health infrastructure that there are unique systems in place to ensure schools have access to students' immunization information.

The Minnesota Immunization Information Connection (MIIC) is a powerful tool for schools to support families in ensuring immunization information is up to date at school. Contact MIIC to create a MIIC account.

Frequently asked questions about schools and MIIC

Schools are required to complete the Annual Immunization Status Report (AISR) every year by December 1st. The AISR reporting responsibilities are assigned by the school district (most often to the school nurse) and results are available online and provided to each school district after they have been reviewed. The directions for how to complete the AISR are online and should be reviewed prior to starting.

Infectious Diseases

Keeping students healthy is the primary goal of the licensed school nurse and the school health services program. School nurses accomplish this task through these key strategies:

• Promoting prevention measures
• Monitoring and requiring immunizations
• Following exclusion guidelines for various conditions
• Reporting specified illnesses to the Department of Health
• Infectious disease management in the population

School Health Services Role When Students are Ill

The Infectious Diseases in Childcare Settings and Schools Manual provides guidance for both general, unidentified illness and for diagnosed illnesses. In this manual you will find critical information about how conditions are spread, their contagious period and when and for how long students should remain home if diagnosed. If there are other special concerns related to a specific condition, they are outlined as well. For many conditions the manual has both a technical fact sheet for use in the health office and a parent sheet that can be printed for families.

Some conditions are of special concern and need to be reported to the Minnesota Department of Health immediately. There is a list of reportable conditions on MDH website.

In schools there are additional guidelines for certain conditions:

Chickenpox and Shingles Reporting - Schools are to report all suspected and confirmed cases of chickenpox at their school, even if they have not been diagnosed by a healthcare provider. Suspect and confirmed cases of shingles in children under 18 must also be reported. Schools should report using the Vaccine Preventable Disease (VPD) Reporting Form.

Chickenpox can sometimes be difficult to distinguish from other rash illnesses, such as hand, foot, and mouth disease. For this reason, MDH recommends laboratory testing for all suspected cases of varicella. Because many cases are not seen by a health care provider, MDH provides home test kits for varicella. Test kits can be sent directly to household or to schools and child cares to distribute to families. Varicella Testing at MDH is provided at no charge. 

Respiratory Illness Outbreak and Gastrointestinal Illness (GI)

Respiratory Illness Reporting includes COVID-19, Influenza, Influenza Like Illness (ILI), or any illness with respiratory symptoms even if there is not a diagnosis.  Schools should report via the Respiratory Illness and Gastrointestinal Illness Outbreak Reporting form when 10% of enrolled students in a building are absent from school on a given day with respiratory illness symptoms and/or a respiratory illness diagnosis. 

Influenza Surveillance Protocol and Frequently Asked Questions

Schools and Child Care COVID-19 Best Practice Recommendation and Case Reporting

School Health Personal Influenza Information 

For gastrointestinal illness, schools should report via the Respiratory Illness and Gastrointestinal Illness Outbreak Report form when the number of students absent with GI illness exceeds the school’s established baseline (e.g., double the number of absences due to GI symptoms).

Outbreaks at Schools, Child Care, and Long-term Care Facilities

Attendance staff should be instructed to ask what a student's symptoms are when families call to notify of illness; this will help to clarify numbers of concern. The school nurse should develop a system for regularly surveying attendance numbers and watching for areas of concern.

Contact for questions.

• For respiratory illness questions email health.schools.covid19@state.mn.us or health.vpd.report@state.mn.us.
• For GI questions contact health.foodill@state.mn.us or 1-877-FOOD-ILL (877-366-3455).

School nurses also work closely with MDH regional field epidemiologists, as conditions present. MDH epidemiologists will work closely with you to monitor the situation.

Families should be provided with guidelines for when to keep their students home from school related to illness.

Other helpful resources:

Hand Hygiene

Cough hygiene

What is a school health record?

The school health record is an official government document that is the preparation and assembly of written and electronic records to describe health care provided and the reasons for providing care. It is essential for communication with health care providers and families. It describes the collaboration and coordination that occurs and provides continuity of care. It should also be a direct reflection of the professional nursing practice that is provided.

Minnesota Statute 144.29, Health Records: Children of School Age, outlines the responsibility of all schools to keep a permanent public health record for every student. It needs to be kept in a way that can be transferred with the student if they transfer within the state. It also requires that the record contain the health data defined in Minnesota Statute Chapter 13.32, subdivision 2. There are many additional details of this statute that should be considered when developing a school policy.

It is important for districts to establish policies regarding school health records. This policy should include:

• Clearly defined method for adding and including additional information and documents to the record
• A description of who is responsible for the maintenance of the record
• How records will be kept secure, both physically and electronically
• A method for the closure and transfer of the record
• A standardized and accepted list of abbreviations
• A record retention schedule

How is the school health record used?

The uses of the health record include:

• Describes the baseline health status
• Organizing and recording all of the health information collected
• Identify the health needs for the educational process
• Showing and documenting the services of the school nurse and other school staff
• Providing accountability to students, parents and guardians about the care provided
• Providing information for supervisory and peer audits for quality assurance and program outcomes
• Continuity of care for changes in schools or staffing
• Making referrals to other health care providers and coordinating care with other partnering agencies
• Conducting nurse, parent, teacher conferences
• Means of understanding information in an emergency
• Clarification when there are legal questions or concerns

What is included in the health record?

Minnesota Statute Chapter 13.32, Subdivision 2 highlights elements that must be kept in the health record, which is part of the educational record:

• Health data concerning students, including but not limited to, data concerning immunizations, notations of special physical or mental problems and records of school nurse
• Pupil census data, including emergency information and family information
• Data concerning parents and private data on individuals but may be treated as directory information if the same procedures that are used to designate student data as directory data under subdivision 5 are followed

Additionally, the health record should include:

• Early childhood screening information should be kept in the student health file as well, per Minnesota Statute Chapter 121A.17.
• Laboratory findings
• Medical or therapy reports
• Medication or treatment orders
• Parental consents
• Health care plans
• Health related correspondence
• Documentation of parent or health care provider conference outcomes

Key Elements of Documentation

The school health record is a legal document so procedure and expectations should be clearly outlined. Best practices in documentation:

• Confidential information only accessible to those with "legitimate right to know"
• Accurate, objective, concise information
• Correct grammar, spelling and punctuation
• Well organized in a way that is systematic and allows for information to be retrieved
• Only using abbreviations that are on the district's list of standard abbreviations
• Date (including year) and time of the care provided
• Date (including year) and time of the documentation, if provided at a different time than care was provided. *All documentation should be entered as soon as possible following delivery of care.
• Signature and title of the person providing care
• Title can be abbreviated using standard abbreviations (ie., RN, LPN, UAP)
• If initials are used in place of a full signature space should be provided and easily accessed that has the complete signature for reference
• Use quotation marks to indicate the exact words used when appropriate
• Only documenting objective information about the encounter
• Entries should be comprehensive and reflective of the providers full scope of practice
• Including all relevant statistics, observations or assessments, actions taken and outcomes
• Specific description and outcome of the treatment, procedure or medication provided
• The date and time of any contacts made on the students behalf, who you contacted (i.e., parent, providers) and method of contacting them (i.e., email, phone)
• Record referrals completely and specifically
• An ongoing record of who has reviewed the health record including date and full name of the person reviewing
• Students and parent/guardians can add to a student's health record per State of Minnesota Government Data Practices, Minnesota Statute Chapter 13.
• Document the annual review of health records per Minnesota Statute 144.29

Districts may use electronic or paper documentation systems. Depending on what type of system a district uses, specific details should be considered.

Paper documentation:

• Legible
• Written in blue or black ink
• No erasing or use of white out
• A single line through the entry is made when there is an error, so that the original information can be read. The word "error," the signature of the person making the correction and the date of the correction should be written at the closest point possible to the correction
• No blank lines between the entries, if a blank line is accidentally left, draw a line through the center of any unused lines
• Kept in a central, locked location

Electronic Documentation:

• No erasing, ensure that the data system captures the original entry and documents who and when the correction was made, with a place for entering why the correcting is being made
• Password protected and a policy that determines the frequency of password changes
• If using an electronic signature, ensure that it is spelled correctly, with accurate licensure or title attached
• Over write protection
• Strong back up system

Minnesota Statutes §§ Chapters 148.171 to 148.285 The Nurse Practice Act does not give specific reference to documentation. However, both courts and liability insurers have established that existing documentation is "the best evidence that a nurse has met professional standards when delivering patient care." In any question of malpractice, the courts judge whether a given action failed based on the records documenting and/or testimony regarding the situation. Adherence to district health record policies and procedures are also commonly reviewed.

The court will review "appropriate standards of care" along with the documentation and testimony. Including standards such as those produced by professional nursing organizations which spell out the criteria for documenting care and maintaining records and record keeping systems. The Minnesota Department of Administration can provide guidance related to records and data privacy.

The 2014 revision of the Minnesota Nurse Practice Act added a section of accountability to the scope of practice for both registered nurses and licensed practical nurses.

Documentation demonstrates accountability, provides a tool for quality assurance, and substantiates the level of care for legal purposes. Recording care given demonstrates compliance with professional standards spelled out in the Nurse Practice Act and applicable to all settings where nurses are employed. Finally, aside from the necessary record keeping for the individual student, documentation furnishes useful data for appropriate evaluation, student outcomes, and research related to the school health program and for continuity of care when a student moves.

The value of the student health record lies in the information it contains and the manner in which it is used. An effective written account of the facts and events related to the individual's health should focus on the student and his/her needs, and it must be accurate, cumulative, specific, objective and private. This record should contain a list of problems or needs to which an individual health plan could be developed, sequential narrative notes, and outcomes of the plan including specific procedures or interventions are recorded. The problem oriented health record offers consistent format for documenting and communicating student health.

Other documentation that may be maintained in general health-related records and files include delegations to non-licensed staff; in-service training; incident/error reports, building or grounds inspections; health activity assessments, staffing reports, or summaries; and data collection or program evaluation reports.

Use and Maintenance of the School Health Record

Health care which is relevant to the student's educational progress is to be entered into the student health record (e.g., medication administration, special diet, or impaired vision or hearing, procedures such as postural drainage, nebulizer treatments, cauterizations, etc.). This record is still regarded as private, and access is limited to eligible students, parents/guardians, and authorized school personnel. The licensed school nurse, whether employed by the school district or public health agency, is responsible for keeping and management of the records.

Since the student health record (electronic or paper) is a legal document, no form or information may be removed and destroyed once it is filed within the chart. The question of how long records are to be kept should be addressed in the Local School District's Record Retention Schedule and with the local school district record retention administrator. If the district does not know the duties of the record retention administrator Minnesota Statute § Chapter 13 of the Government Data Practice Act spells these duties out. There are a number of Minnesota rules and statutes to address the proper handling of this information. It is recommended that Local School Districts consult with school nurses and school district attorneys in formulating health record retention policies and procedures for handling student health records.

Besides the requirement to keep records, school districts must also adhere to Minnesota Statute § Chapter 13 regarding collection, classification, handling, review, dissemination and destruction of data. These statutes, known as the Government Data Practices Act, are briefly described as follows:

Retention of Records

Each school should have a person who is designated as the responsible authority regarding record retention and sets up the record retention schedule.

If the school does not set up their own record retention schedule they can adopt the general district general record retention schedule for school districts.

The general classification system of government data is a way of delineating who is authorized to have access to information. For purposes of school health services provided to students, the licensed school nurse should become familiar with the classification of data on individuals, further subdivided into public, private and confidential data. (The Act dictates that all government data are public unless otherwise classified.)

Communicating Health Record Information

Communicating with School Personnel

There may be circumstances where information in the student record may need to be shared with certain school personnel to enhance the educational progress of the student or protect his/her safety or well-being. Staff may need to be alerted to signs or symptoms of a medical problem and offer a course of action. In such circumstances, the permission of the parent or legal guardian and student, should be obtained prior to disclosure. Information in the student health record, however, may be shared with appropriate school personnel as necessary to protect the well-being or safety of the student. This is considered "legitimate right to know."

In accordance with the law, local policies and professional standards, the school nurse has the specialized skill, judgment and knowledge to decide which health information is educationally relevant and the school personnel requiring that information. Sharing the school health/education information for any other purpose is inappropriate and unethical. Mishandling of data could result in financial or civil liability and/or professional discipline.

It is important to carefully document who has reviewed the school health record. Access to the student health/medical information should be based on "legitimate educational interest." A log should be kept with the record indicating who has had access to the record and when.

Communicating with Others Outside of the School

If the school nurse has concerns about the licensed health care prescriber orders, or wants to share information that may be relevant to the treatment regimen with the licensed health care prescriber, the school nurse and licensed health care prescriber may communicate with each other regarding the medical orders and treatment regimen without written authorization of the parent/guardian. The Health Insurance Portability and Accountability Act (HIPAA) allow health care professionals to share protected health information if it is for treatment purposes. Furthermore, regardless of the healthcare setting, State licensure statutes and professional standards of practice for nurses and physicians require nurses to question and clarify medical orders, when indicated, before carrying them out. They also require physicians to provide nurses with sufficient information for safe execution of the orders/treatment plan. Therefore, such communication is based on State law and necessary for public policy reasons.

Releasing records though, unless going to another public school system, requires a parental/guardian release.

In Minnesota there is a state law that specifically requires the disclosure of immunization records to schools officials. Therefore, health providers can share immunization information with school officials without the written authorization of the parent/guardian.

There are two circumstances under which schools may release student health data. According to Minnesota Statute § Chapter 13.32 schools may disclose data for two specific purposes:

• In health and safety emergencies.
• To administer immunization programs or during an epidemiological investigation.

The students/parents/guardians may add comments to the record. This is done according to the State of Minnesota Data Practices Act, Minnesota Statute § Chapter 13. If there is any question as to whether the school's policies and procedures are in compliance with the Minnesota Government Data Practice Act, Minnesota Statute § Chapter 13, the school should discuss its policies with its legal counsel/school attorney.

Tennessen Warning

Whenever private or confidential data are collected, there is a requirement that the subject of that data be given certain information or notification. This requirement, also known as the Tennessen Warning, specifies that the person who is the subject of the data must be told the following:

• Why the data is collected.
• How the data will be used within the collecting agency.
• Whether the individual can refuse, or is legally required to provide the data.
• What the consequences are to the individual of supplying or refusing to supply the requested data.
• The identity of others authorized to receive the data.

This statute also requires that schools safeguard records and dispose of records properly.

FERPA

School health information is considered part of the student record. In some cases, confidential information regarding sensitive health issues covered by minor consent may not be appropriately documented in the health record, since that is part of the student record. Family Education Records Privacy Act (FERPA) (20 U.S.C. §1232g) does allow for personal notes.

Personal notes regarding a student are not part of a student's educational record under the following conditions:

• The content of the notes is not shared with others,
• The notes are not included in any part of the student's official education record and are kept in the sole possession of the maker of the record;
• The notes do not result in any institutional or administrative decisions regarding the student; and
• The notes are intended solely as an extension of memory.

These standards all must be satisfied if records are to be treated as "notes." Merely labeling a document as "notes" will not exclude it from the definition of education records as a matter of law. If personal notes are placed in the student's official records, or made available to others, they become part of the student's education records and subject to all of the provisions of FERPA.

School health services programs must address documentation of sensitive information in their local policies. Helping students who seek counsel and assistance must be an integral part of a comprehensive services system dealing with substance abuse, sexually transmitted disease, HIV infection, pregnancy, contraception, abortion, and mental and emotional disorders.

HIPAA

When schools are creating their data privacy policies and practices a clear understanding of the interplay between HIPAA and FERPA is essential. Some key documents to consider are:

• CDC Health Information and Privacy FERPA and HIPAA
• Joint Guidance on HIPAA and FERPA

Minor's Consent

School nurses serving students should have a strong understanding of the Minor's Consent Law (144.343).

Specific Services

A minor may consent for medical, mental, or other health services for the following:

• To determine the presence or treatment of pregnancy and conditions associated with pregnancy
• For sexually transmitted infections
• For alcohol or other drug abuse (Minnesota Statute § Chapter 144.343,Subd. 1)
• Hepatitis B vaccinations (Minnesota Statute § Chapter 144.3441) and
• Blood donation (only those 17 and over; a 16-year-old can donate with written consent from a parent or guardian) (Minnesota Statute § Chapter145.41).

Emergency Treatment

Health services may be provided to minors without the consent of a parent if, in the health professional's judgment, treatment should be given without delay, and if obtaining consent would result in delay or denial of treatment (Minnesota Statute § Chapter144.344).

Abortion

Minors seeking an abortion must notify both parents of the intended abortion and wait 48 hours, or seek judicial approval for the procedure. A court may authorize an abortion if it finds either: That the pregnant minor is mature and capable of giving informed consent, or
That authorizing the abortion without notification would be in her best interests. An expedited, confidential appeal is available to any minor for whom the court denies an order authorizing an abortion without notification. An order authorizing an abortion without parental notification is not subject to appeal (Minnesota Statute § Chapter 144.343, Subds. 2-7).

Marriage or Giving Birth

Any minor who has been married or has given birth may consent for personal medical, mental, dental, or other health services or for services for the minor's child (Minnesota Statutes § Chapter 144.342).

Voluntary Institutional Treatment

Any person 16 years or older may request informal admission to a treatment facility for observation or treatment of mental illness, chemical dependency, or mental retardation and may give valid consent for hospitalization, routine diagnostic evaluation, and emergency or short-term acute care (Minnesota Statutes §§ Chapters 253B.03, Subd. 6(d);253B.04, Subd. 1).

Access to Health Records

Parents and legal guardians have access to their minor children's medical records, unless the minor legally consents for services specifically listed under the Consent of Minors for Health Services statute (Minnesota Statutes §§ Chapters144.341-144.347). In that case, parents or guardians do not have access to the minor's health care records without the minor's authorization (Minnesota Statutes § Chapter 144.291, Subd. 2, para. (g)). However, if a health professional believes that it is in the best interest of the minor, the health professional may inform the minor's parents of the treatment (Minnesota Statute § Chapter 144.346).

Living Apart from Parents and Managing Own Financial Affairs

A minor living apart from his or her parents or legal guardian and who is managing his or her own financial affairs may consent for his or her own medical, mental, or dental care services. This exception applies to a minor regardless of whether the minor's parents have consented to the minor living apart, or regardless of the extent or source of the minor's income (Minnesota Statute § Chapter 144.341).

Representation to Persons Rendering Service

If a minor represents to a health professional that he or she is able to give effective consent for medical, mental, dental, or other health services, but is in fact not able to do so, his or her consent is effective if relied upon in good faith by the person rendering the health service (Minnesota Statute § Chapter 44.345).

Financial Responsibility

A minor who consents for health services is financially responsible for the cost of the services (Minnesota Statute § Chapter 144.347).

Record Review

As stated in Minnesota Statute § Chapter 144.29 Health Records: Children of School Age. Periodic record review is an essential component of health record maintenance. It helps to assure that all charting is being done according to established policies and procedures. It is required in "...at the beginning of each school year the health record of all pupils shall be reviewed by a teacher, school nurse .or other professional person" which most often occurs through the use of a Health History form included in back to school registration.

If a record review reveals that documentation is not being done according to policy, prompt corrective action to improve documentation procedures is appropriate.

Prevention and early intervention are foundational in making sure that every child in Minnesota reaches his or her full potential. Screenings and early access to care also ensure the most effective medical monitoring and treatment. The best practices in screening are outlined below.

Early Childhood Screening

Minnesota Statute 121A. 17 School districts are required to complete an early childhood developmental screening on all children prior to entering kindergarten, with programs targeting children ages three and four (Minnesota Statute 121A. 17). The screening program must include, at least, the following components: developmental assessments, hearing and vision screening, immunization review and referral, the child's height and weight, the date of the child's most recent comprehensive vision examination, if any, identification of risk factors that may influence learning, an interview with the parent about the child, and referral for assessment, diagnosis, and treatment when potential needs are identified.

Forms and program quality indicators can be found at the Minnesota Department of Education Early Childhood Screening page.

Because the school nurse has professional expertise in all of these areas, the nurse is often a vital team member in developing and carrying out high quality early childhood screening programs. School districts receive reimbursement for early childhood screening. Districts may elect to utilize LSNs in screening to assist with funding school health programs.

Hearing and Vision Screening

Hearing and vision screening are not required in Minnesota schools but are HIGHLY recommended due to their significant impact on learning. Completing hearing and vision screening early in the fall is recommended. Hearing and vision screening are often a required component of special education evaluation and annual assessment.

The MDH Child and Teen Checkups (C&TC) has developed a comprehensive hearing and vision screening manuals using evidence-based practice that should be used to provide high quality and effective screenings.

Hearing Screening

Hearing screening is recommended annually for students in kindergarten and grades 1, 2, 3, 5, 8, and 11. Screening should also be completed for new students, students undergoing evaluation for special education services, and as concerns arise. This web page link includes screening forms and materials that can be used for hearing screening.

Schools are responsible for ensuring that hearing screening equipment is functioning properly. Audiometers should be calibrated every year to   ensure the accuracy of the machine's readings. Schools can contact a vendor of their choice.

Vision Screening

Vision screening is recommended in grades 1, 3, 5, 7 and 10. Screening should also be completed for new students, students undergoing evaluation for special education services, and as concerns arise. This web page included forms and materials that can be used for vision screening.

Schools are responsible for ensuring that vision screening equipment (eye charts) are up to date to meet best practice recommendations.

Hearing and Vision Training

MDH through Child and Teen Checkups (C&TC) provides best practices training for vision and hearing screening. Training is open to nurses, school health para personnel, or volunteers in school who perform vision and hearing screening with students. This training helps to ensure consistency in screening and the referral process. It is highly recommended to complete this training before providing screening. To register or to learn more visit MDH C&TC Trainings or to C&TC Training Registration.

In collaboration with BrightWorks, A Minnesota Service Cooperative, five videos were developed to provide a quick review on hearing and vision screening in schools. These videos are a supplement and not a replacement for the C&TC Vision and Hearing Screening Training or the Vision and Hearing Screening Manuals.

The videos cover hearing and vision screening specific for the school nurse. There are also videos on vision and hearing screening for volunteers, and others such as nursing students who have been previously trained in vision and hearing screening. A short 3-minute video was developed to help elementary age students learn what to expect and alleviate any apprehension when participating in vision and hearing screening at school. 

State Aid to School Districts: General Fund and Categorized Aid

The schools use a variety of funding resources to finance school health services. The traditional source of funding is the regular K-12 general aid budget. Equipment purchase is dependent on school policy and is sometimes funded through the capital budget. School health services can also be funded through categorical educational programs depending on the guidelines of those programs. For example, non-public school health services are provided by Minnesota State statute through categorical aid. Schools recoup costs by billing insurance programs and other third party payers for health services provided directly to individuals. Community agencies and organizations also provide funding for comprehensive programs or for individual health services.

Schools must explore a variety of sources in their attempt to fund health services for students. Following are brief summaries of basic information for schools who wish to seek remuneration from third party payers such as Medical Assistance, MinnesotaCare, health maintenance organizations, and insurance companies.

Special Education Educational Categorical Aid

Health services, when provided as part of an individual education plan (IEP), are funded as special education related services. "Related services" are transportation, and developmental, corrective and other supportive services as are required to assist a child with a disability to benefit from special education. These include several health related services that must be available, including speech pathology, audiology, psychological service, physical and occupational therapy, early identification and assessment of disabilities, counseling services, school health services, school nursing, social work services in school, and medical services for evaluation and diagnostic purposes only.

A May 8, 1992 memo from the Minnesota Department of Education to Special Education Directors clarifies: "Nursing services are eligible for state and federal special education reimbursement when those services are directly related to the learner's disability and are necessary for the learner to benefit from the educational program as defined in the learner's IEP (Individual Educational Plan)."

More information about related services can be found on the MDE Related Services Page.

Non-public School Health Services

Non-public health services fund health services to students enrolled in private, parochial or home schools. To participate in the Health Services Program, students must be enrolled in grades kindergarten through twelfth grade in a participating non-public school.

The Nonpublic Pupil Aids are intended to reimburse local public school districts for costs incurred in the direct provision of health services to nonpublic students. Public School Districts are charged with providing the services which means all services must be provided by qualified staff employed by or under contract with the public school districts. Districts are expected to provide the same specific services to the nonpublic students as are provided to the public students within the district, without exceeding the reimbursement rate. Since the reimbursement rate is a statewide average, low spending districts may be able to provide equal services without spending the entire maximum reimbursement. In these cases, once the district has reached the equal treatment threshold they are expected to stop, as going beyond this point would mean equal treatment is no longer being met.

The funds cover salaries, benefits, travel and supplies used by the health professional. Only supplies brought to the site by the district health professional for usage in the fields of physical or mental health are eligible for reimbursement. These supplies are not to be used by nonpublic school staff and the program does not purchase supplies for nonpublic schools. Nonpublic schools are expected to purchase their own medical supplies which would be available for the nonpublic school staff to use when the visiting public school health professional is not at the nonpublic school.

This is a public school program designed to service nonpublic students and the public school makes the staffing and spending decisions. Nonpublic schools do not have the authority to spend the money generated by this program. The Nonpublic Pupils Aids program is not intended to be comprehensive and is designed to supplement a nonpublic school's own efforts to meet the health needs of their students.

Home school students are considered non-public students and may access health services through the local public education district.

More information can be found on the MDE Nonpublic page

The associated legislation is MN Statute 123B.44 Provision of Pupil Support Services

Child and Teen Checkup (C&TC) and Early and Periodic Screening (ECS)

Child and Teen Checkup is a federally mandated component of Medicaid which is outlined in the Minnesota Medical Assistance state plan. All persons from birth to age 21 who are eligible for Medical Assistance or Minnesota Care are also eligible for C&TC/EPSDT services.

The intent of C&TC/EPSDT is to enable MA and MinnesotaCare eligible children to receive screening, well child supervision visits, and necessary treatment. Eligible providers in Minnesota are physicians, outpatient hospitals, community or public health clinics, nurse supervised screening clinics, early childhood screening clinics (ECS) and school districts.

Early Childhood Screening is a state authorized and state funded program. School districts are responsible for the program. All children enrolled in public school must show evidence of a sensory and developmental screening upon kindergarten enrollment. The school, often in coordination with community health agencies, Head Start, and private providers, operate a program that targets children at ages 3 to 4 years. The schools are reimbursed by the state for partial cost of their services. Children may access these services at other sites, including their primary health care provider.

Private Insurance

A school district can ask families if the school district could bill certain costs to the family's insurance but:

Parents/legal guardians can refuse to allow school districts to bill their insurance.

The school cannot refuse to provide or stop a child's services if parents/legal guardians refuse to allow third party billing.

A school or provider cannot bill a family for any remaining balance after the insurance has paid. The school must accept the insurance payment in full. (Also applies to Minnesota Health Care Programs [MHCP])

The billing of services to a family's private insurance may affect the family's annual cap or lifetime maximum. Some companies raise the family's premiums if there are too many expensive claims.

Resources for third party payment exist in a constantly changing environment. As changes happen in government programs and health care delivery, the way in which school health services may utilize third party payers as funding sources will shift and change.

Interagency Relationships/Contracts

School health services may be provided through interagency agreements and/or contracts with a local private or public agency. The contract arrangement should describe the services to be provided as well as the source and method of payment. In these instances, the cost of providing services can be financed from a variety of sources depending on the services provided. The school may be billed for the entire cost of a service or the school.

The contracted agency can bill other payers, such as Minnesota Health Care Plan (MHCP), for health services provided. MHCP requires that the billing agency:

• Provide services according to the individual's IEP that specifies the amount, type and duration of the education related service
• Has a copy of the IEP in their record and written verification from the school district which specifies in detail which portions of the IEP related services will be performed by the non-school district provider.

Local Voluntary and Service Organizations

Local voluntary and service organizations can be solicited to provide funding for specific school health services budget items. For example, a local service club may purchase an audiometer, or blood glucose meter for school health service and student use. Examples of service organizations include Lions Clubs, Kiwanis Clubs, Masons, Rotary, and others. Each service organization has local service programs that they support both with money and time.

Grants

Public and private grants may be a good source of money to start new programs. School districts may receive funding for various school health programs by applying for money granted by the federal, state or local governments, private foundations or nonprofit organizations. While application for these grants may take considerable staff time, it is sometimes an innovative way to fund programs or services not endorsed by other sources.

Schools as Minnesota Health Care Programs (MHCP) Providers

The Minnesota Health Care Programs (MHCP) includes Medical Assistance (MA), MinnesotaCare and General Assistance and Medical Care (GMAC). For the public school district to receive MHCP reimbursement, the school must enroll as a MHCP provider. The school district may bill directly to MHCP or the school district can contract with other non-school district providers who are already MHCP providers. MHCP will not directly reimburse private schools, but can make payments to the public school district for IEP related services for children in that district who are attending private educational facilities. For specific questions on MHCP reimbursement for Individual Educational Plan (IEP)/Individualized Family Service Plans (IFSP) and related school services, contact the Minnesota Department of Human Services Help Desk at (612) 282-5545 or (800) 366-5411.