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DoDEA School Health Services Manual 2942.0 Volume 1 Revised: 2016 DRAFT
the sponsor(s)/parent(s)/guardian(s) and designated emergency contact(s) be
unavailable, the school should make every effort to notify the sponsor’s unit of the
situation.
Special treatments and medications are not considered routine health services.
These procedures require additional consents described in
Section F: F-3 (Medication
Policy) of this Guide. Consent documentation is available in the School Health Services
Manual (SHSM) Forms H-3-2, H-3-9, H-4-8, H-4-9, and H-4-9-1.
The school nurse should follow local military regulations regarding the age of
consent for adolescents. See additional information on adolescent health issues in
Section F: F-11.The school nurse should inform sponsors/parents/guardians of basic school
health services (i.e., school-wide screenings through school newsletters or notes to the
sponsor/parent/guardian). Notice should include which screenings are being
conducted, the targeted population, dates/times, reason for the screenings,
signs/symptoms sponsors/parents/guardians may observe at home that indicate a need
for medical intervention and how sponsors/parents/guardians will be notified of
screening results.
C-8 Documentation and Records Keeping
Maintaining accurate health records is a DoDEA requirement and a standard of
nursing practice and performance. Because of the nature of school health, NASN has
published guidelines for school nursing documentation. NASN recognizes that good
documentation is fundamental to good nursing care and from a legal perspective, “if it
wasn’t documented, it wasn’t done.” All health-related encounters are required to be
documented to provide accountability and high quality nursing care, provide a vehicle
for quality assurance, and to meet legal mandates.
The National Task Force on Confidential Student Health Information discourages
the use of chronological logs with multiple student entries for recording health office
visits or medication administration. Under the PA, sponsors/parents/guardians have
access to their dependent’s records but not to those of other students. Therefore, best
practice calls for the use of individual paper or electronic documentation for each
student’s health care and minimal inclusion of information about other students, while
protecting the other student’s PII. In all DoDEA schools, all health-related encounters
are to be documented in the DoDEA-approved SIS. If an encounter is not documented
via the DoDEA-approved SIS, documentation is accomplished using a SHSM Form H: H-
4-6 (Health Referral Form).
Required information to be documented in the approved DoDEA SIS includes: