Section 11: The Iowa School Nurse

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Bloodborne Pathogen

The purpose of the United States Department of Labor, Occupational Safety and Health Act (OSHA), Occupational Exposure to Bloodborne Pathogens Regulations and Standards, adopted by the Iowa Division of Labor, Occupational Safety and Health Bureau, is to end and reduce employee exposure to blood and other potentially infectious materials (OPIM). The laws require Iowa schools and education agencies, as employers, to develop an occupational exposure to bloodborne pathogens program. The program includes written policy and plan guidelines for employees. The school works with local health agencies, health providers, non-managerial school staff, and school personnel in developing the program and educating personnel, families, students, and the community to prevent potential exposures (United States Code 29 U.S.C. 661 et seq. Occupational Safety and Health Act and U.S. Code of Federal Regulations 29 CFR 1910.1030). The answers to these frequently asked questions are located on the links to the United States Department of Labor [USDOL] Most Frequently Asked Questions Concerning the Bloodborne Pathogens, USDOL Bloodborne Standard Code of Federal Regulations, Iowa Division of Inspection, Appeals and Labor and Iowa Department of Health and Human Services. 

The information contained in this below is not considered a substitute for any provisions of the Occupational Safety and Health Act of 1970 (OSH Act) or the requirements of 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens.

Prevention and control of communicable diseases is included in the school district’s bloodborne pathogens exposure control plan. The procedures will include scope and application, definitions, exposure control, methods of compliance, universal precautions, vaccination, post-exposure evaluation, follow-up, communication of hazards to employees and record keeping. This plan is reviewed annually by the superintendent and school nurse in accordance with school policy.

Schools are required to provide Bloodborne Pathogen training and school nurses often request information regarding the Hepatitis B vaccination series requirements. The de minimus classification for not offering the pre-exposure Hepatitis B vaccination series to school personnel does not apply to healthcare personnel expected to render first aid in the course of their work. The answers to the  following commonly asked questions are located in the United States Department of Labor Occupational Safety and Health Administration Standard: 1910.1030.

Scope: https://www.osha.gov/laws-regs/standardinterpretations/1993-02-01-0#hazards

Bloodborne Pathogens Frequently Asked Questions 

1. Question: Who in the school or district is covered by the standard? 

Answer: (Located under “Standard” Question and Answer 1) 

2. Question: Are school nurses, school employees who regularly provide first aid or employees who perform janitorial duties covered by the standard? 

Answer: (Located under “Standard” Question and Answer 6-7) 

3. Questions: When must Hepatitis B vaccinations be offered to employees, can a Hepatitis B titer serological screening for the employee be required by the district or school, can a school employee refuse the vaccination, may the school or district require to have the employee sign a declination form, who is responsible to pay for the vaccine and how to handle post-exposure? 

Answer: (Located under “Standard: Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-up Procedures” Question and Answers 50-64) 

4. Question: Who keeps employee’s medical records and for how long related to Hepatitis B vaccination status and any medical records relative to the employee's ability to receive the vaccination; copies of all results of examinations, medical testing and follow-up procedures; copies of the healthcare professional's written opinion; and copies of the information provided to the healthcare professional? 

Answer: (Located under Standard: “Recordkeeping” Question and Answers 76-77) 

5. Question: How would a school employee obtain a record of their immunization status? 

Answer: A school employee would contact their former or current healthcare provider. 

6. Questions: What is considered regulated waste, how is it disposed of and how should sharps be handled for employees, visitors, and students in a school or district? 

Answer: (Located under Standard: “Regulated Waste” Question and Answers 36-42) 

7. Question: Would an online course or video watched by school or district personnel meet the training requirement for bloodborne pathogens? 

Answer: No. The standard for the course includes a requirement for the opportunity to have interactive questions and answers with the person conducting the training session and the person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace that the training will address. The trainer must be accessible to employees during the time of training. (Code of Federal Regulations [CFR] 1910.1030(q)(2)(vii)(N); CFR 1910.1030(q)(2)(viii) . 

8. Question: What are the minimum training program requirements for Bloodborne Pathogens?

 Answer: (located by following the link to the Code of Federal Regulations (CFR) and reviewing CFR 1910.1030(g)(2)(vii)(A) to CFR 1910.1030(g)(2)(ix)(C) 

9. Questions: When does a district or school complete a Bloodborne Pathogen educational course, who provides the course, what qualifications are required to teach the course, how long are training records maintained?

Answer: (Located under Standard: “Communication of Hazards to Employees” Question and Answers 70 to 75 and under Standard: “Recordkeeping” Question and Answers 79-80) 

10. Question: Does the Iowa Division of Labor provide educational resources for Bloodborne Pathogen and other OSHA Trainings? 

Answer: Yes. The Iowa OSHA Education offers free training on safety and health topics. Consultants from Iowa OSHA are also available to answer questions, attend seminars and conferences. Employers may request training by completing the request for services by educational staff. Schools may request training resources at: Iowa OSHA Education Services 

11. Questions: What type of personal protective equipment (PPE) do school personnel need to wear when working with blood or other potentially infectious materials (OPIM), who is responsible for providing it? 

Answer: (Located under Standard: “Personal Protective Equipment” Question 28 and 30) 

12. Question: When should gloves be changed, what are universal precautions, are gloves required when administering an injection and what alternatives are available for employees who have allergies to the gloves provided by the school or district? 

Answer: (Located under Standard: “Gloves” Question 32-34 and under Standard: “Universal Precautions” Question 15) 

13. Question: Where would a district or school report communicable diseases? 

Answer: The Iowa Health and Human Services has a list of diseases in a table with the time frame specified and how to report that is required by Iowa Administrative Code [641] Chapter 1. (Located under the Iowa HHS Reportable Communicable Disease and Infectious Conditions webpage) 

14. Question: What contents should be included in an Exposure Control Plan and where can a sample sharps injury log be located? 

Answer: OSHA has a sample exposure control plan which is required by the Bloodborne Pathogens Standard and a sample sharps injury log located at Model Exposure Control Plan.

Occupational Safety and Health Act (OSHA) Publications and Fact Sheets

OSHA has printable publications located at: https://www.osha.gov/publications/bytype/fact-sheets

Clinical Laboratory Improvement Amendments (CLIA) 

The state department of education maintains a certification waiver for all Iowa schools (since 2010). A school is considered a facility where school nurses or other licensed healthcare providers in school based health centers perform laboratory testing in the course of the school day, licensed practice and policy. Parents are required to provide consent for all tests completed with students. 

Examples include, but are not limited to: 

• rapid antigen detection tests completed by licensed healthcare providers in school based health centers to culture for group A streptococcus,
• urine specimens to monitor for ketones of students whose parents have provided testing strips,
• blood glucose monitoring for students whose parents have provided supplies,
• urine specimen supplies for drug testing and alcohol testing (QED 150 saliva tests) for trained school nurses and other licensed health personnel to complete the department of transportation [DOT] testing requirements for licensed school transportation personnel for post-accident, random, and when there is suspicion. 

Schools (considered a facility) and other services provided in the facility performing less than 15 types of tests in the course of business fall under the state waiver. 

The Clinical Laboratory Improvement Amendment of 1988 allows waived tests cleared by the FDA to be conducted by facilities who are certified (Regulation 42 CFR 493).Without the state waiver, schools (public, accredited, independent accredited and charter) would each be required to pay a certification fee.

Common Childhood Illness Exclusion

A child should be temporarily excluded from an education or child care setting when the child’s illness causes one or more of the following:

1. Prevents the child from participating comfortably in activities.
2. A need for care that is greater than the staff can provide without compromising the health and safety of other children.
3. An acute change in behavior: lethargy, lack of responsiveness, irritability, persistent crying, difficulty breathing, or a quickly spreading rash.
4. Fever with behavior change or other signs and symptoms in a child older than 2 months (e.g., sore throat, rash, vomiting, diarrhea).
   1. For infants younger than 2 months of age, a fever with or without a behavior change or other signs and symptoms.
   2. A child with a temperature elevated above normal is not necessarily an indication of a significant health problem
   3. A fever is defined as:
      1. For an infant or child older than 2 months, a fever is a temperature that is above 101 degrees F [38.3 degrees C] by any method.
      2. For infants younger than 2 months of age a fever is a temperature above 100.4 degrees F [38 degrees C] by any method
      3. Temperature readings do not require adjustment for the location where the temperature is taken.

Some students may have chronic health conditions or disability that result in the child vomiting and does not indicate that the child is ill. Remember that a symptom alone does not necessarily mean a child must be sent home. In unique situations, the child may have an individualized health plan to address the implementation of delegated interventions to address their needs. Always defer to the individualized plan prior to removing a child from their education program.

Contracted Agency Nursing

Parents may utilize contracted agency nurses in their home to provide nursing services. When the student reaches school age or is eligible to access educational programs, teams will make a determination of related service needs. 

Special Healthcare Needs Assessment:

The school nurse employed by the district may be asked to complete the “Special Health Care Needs Assessment Form”. The school nurse working under the auspices of the school completes the Special Healthcare Needs Assessment Form and provides it to the Special Education team. This piece of data is important when the team is making a determination regarding the level of related services to provide based on the school nurse’s licensed delegation decision. A team may make a determination to provide more related services (i.e. the school nurse has indicated in documentation that they can delegate a task to a paraprofessional using professional nursing judgement and accountability, but the team would like the child's 1:1 contracted agency nurse). This form assists both the licensed educator and the licensed nurse. Parents may request unlicensed family to provide care or provide a medical note stating a family member can provide a service. As a reminder, a medical provider does not prescribe educational services. 

Licensed educators and licensed nurses are aware that parents sometimes do not understand that a school is a business and the licensed providers are held to higher regulatory standards (IAC 282.25.3; IAC 655.6) in the provision of care than the care provided by the parents at home. If the care requires licensure or qualification, the school must provide the appropriately licensed or qualified personnel, similar to other businesses.

Contracted Nursing Medicaid Guidance 

If the school or school sponsored program has a student who receives services at school or a school sponsored program from a home health private health care agency nurse, as an extension of the services provided in the home, it is recommended that the student’s Individualized Education Program (IEP) team: 

(1) review the necessity of nurse level services; 

(2) if nurse level services are found necessary, review the necessity of using a private health care agency nurse instead of an employee nurse; and 

(3) review Iowa Department of Human Services Informational Letter 1935-MC-FFS. The letter states that “Schools may choose to contract with health care agencies to provide the needed services. Contracted services are the responsibility of the school and the contracted providers should bill the school and not Medicaid for services written in the student’s IEP. While the IEP might order nursing services, the school is not obligated to use the private duty nursing agency that provides services in the student’s home before and/or after school. In addition, an IEP might require health paraprofessional services supervised by the school nurse if private duty nursing services are not medically necessary. If rejected by the IEP team, the private duty nursing agency cannot fail to provide services at the other authorized times of day. The titles below are tools your district might use to determine the necessity of nurse level services and to provide guidelines for private agency nurses.”

Sample Personnel Form:

Guidelines for Contracted Health Providers Schools or programs can adapt this guideline. It is a basic agreement that the contracted agency personnel will follow policies and expectations (noninclusive examples: maintaining confidentiality, dress code, etc.)

Change in Personnel or Unfilled Positions:

If the IEP determines the school will provide a registered nurse, then the school must provide a registered nurse. If the student's registered nurse resigns from the contracted nursing agency or is unable to attend the child’s school or program, the school or program must provide the related services outlined in the child’s individual education program (IEP). (Example: The 1:1 contracted agency nurse resigns effective immediately from their employment. The school registered nurse would become the 1:1 nurse for the student that the agency could not fill until a replacement registered nurse is found by the school or agency). 

Documentation Requirement: 

The school or program is required to document health services provided, so if a student requires a 1:1 nurse and the school or school sponsored program uses an agency, the agency nurse would need to supply documentation to the school or program as part of the student's school or program  health record to meet IAC 281.14.2 and documentation that the program or school provided the health services.

School Nurse’s Role: 

The school nurse working under the auspices of the school or program must develop an Individual Health Plan. This is not the agency plan used by the community or agency provider.  The reference guide to complete the IHP template is located in this document. Also, this is in the Nurse Practice Act when working with an LPN: 

The licensed practical nurse shall be permitted to provide supportive and restorative care to a specific student in the school setting in accordance with the student’s health plan when under the supervision of, and as delegated by, the registered nurse employed by the school district  

Also, located in IAC 281.14.2:  “Individual health plan” means the documented plan of care utilizing the nursing process as defined in 655—Chapter 6 for evidence-based management of the student’s ongoing special health service in the educational program. The school nurse may develop this plan in collaboration with the education team. The plan also includes a provision for emergencies to provide direction in managing an individual’s health condition (stable or unstable). Documentation of evaluation and updates to the plan are completed as needed and at least annually. 

“Licensed health personnel” means a licensed registered nurse, licensed physician, licensed physician assistant, or other licensed health personnel legally authorized to delegate or provide special health services and medications under the auspices of the school.

School Nurse delegation to the Contracted Agency Nurse (a-d):

1. Delegation between an RN to an RN or LPN:  655.6.2(5) The registered nurse shall apply the delegation process when delegating to another registered nurse or licensed practical nurse by A-G(3).
2. b. Delegation between an RN to an unlicensed assistive personnel (anyone not licensed as a registered nurse): 655.6.3(9) The licensed practical nurse shall apply the delegation process when delegating to an unlicensed assistive personnel (UAP) by A-G
3. c. Refresher on  LPN Functions (IBON): https://dial.iowa.gov/licenses/medical/nursing-professional-midwifery/nursing-practice/rnlpn-role-scope#lpn-functions
4. Completed Consent/Delegation documentation:  The school nurse would complete a consent and delegation document for all delegated care to the contracted agency nurse.

 Other considerations for the school nurse (noninclusive list)

• How will field trips be handled?
• How will full day education programming health service delivery be provided?
• Does the child require delivery of health services when accessing transportation?
• Are  parents willing to sign a release of information, not only with the student's provider but also with the local EMS if the student has any life-threatening condition? 

The student is an integral member of the school community. The more engagement and communication between the student, their family, education team, community partners, and their healthcare provider(s) builds a greater safety net around the student.

Confidentiality

Paraprofessionals need to ensure their understanding of confidentiality: 

1. The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records.
2. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education.
3. FERPA gives parents rights to their children’s education record(s) to inspect, review and prevent disclosure of personally identifiable information.
4. Health information is shared by parents. School personnel only share health information with other school personnel if the other personnel have a "legitimate educational interest”
5. Health records created by a paraprofessional or a school nurse is considered an educational record and FERPA applies.
6. The paraprofessional should not create communication and/or educational records using their own personal electronic device.
7. Schools are required to have policies surrounding confidentiality of education records.

Family Education Rights Privacy Act

Nurses who are coming into the professional practice of school nursing from a healthcare work environment are familiar with the Health Insurance Portability and Accountability Act (HIPAA). In schools, the main privacy law acronym is the Family Education Rights Privacy Act (FERPA). 

FERPA is very different from HIPAA. In the school environment, all records created by the school nurse are protected under FERPA. Also, all medical records that parents share with the school are protected by FERPA. 

The only two HIPAA related correspondences that typically occur in schools relate to electronic medicaid billing submission or a school based health clinic visit with a healthcare provider (e.g. ARNP, MD, DO, or PA) (Joint Guidance, 2019). 

It is strongly recommended that school nurses read the Joint Guidance created by the United States Department of Health and Human Services and the United States Department of Education to understand the application of privacy laws to student health records.

The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education.

FERPA gives parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level.  Students to whom the rights have transferred are "eligible students." This is important when reading through the HIPAA/FERPA guidance document.

Parents or eligible students have the right to inspect and review the student's education records maintained by the school. Schools are not required to provide copies of records unless, for reasons such as great distance, it is impossible for parents or eligible students to review the records. Schools may charge a fee for copies.

Parents or eligible students have the right to request that a school correct records which they believe to be inaccurate or misleading. If the school decides not to amend the record, the parent or eligible student then has the right to a formal hearing. After the hearing, if the school still decides not to amend the record, the parent or eligible student has the right to place a statement with the record setting forth his or her view about the contested information.

Generally, schools must have written permission from the parent or eligible student in order to release any information from a student's education record. However, FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions (34 CFR § 99.31):

• School officials with legitimate educational interest
• Other schools to which a student is transferring
• Specified officials for audit or evaluation purposes
• Appropriate parties in connection with financial aid to a student
• Organizations conducting certain studies for or on behalf of the school
• Accrediting organizations
• To comply with a judicial order or lawfully issued subpoena
• Appropriate officials in cases of health and safety emergencies
• State and local authorities, within a juvenile justice system, pursuant to specific State law

Schools may disclose, without consent, "directory" information such as a student's name, address, telephone number, date and place of birth, honors and awards, and dates of attendance. However, schools must tell parents and eligible students about directory information and allow parents and eligible students a reasonable amount of time to request that the school not disclose directory information about them. Schools must notify parents and eligible students annually of their rights under FERPA. The actual means of notification (special letter, inclusion in a PTA bulletin, student handbook, or newspaper article) is left to the discretion of each school.

The United States Department of Education has a 30 minute training on FERPA 101, available at: https://studentprivacy.ed.gov/training

Pupils Rights Privacy Act

School nurses should also understand the Protection of Pupil Rights Amendment (PPRA). PPRA requires local education agencies receiving funds under any program funded by the U.S. Department of Education to protect certain rights of parents and students. One PPRA requirement states that schools must work with parents to adopt policies, unless the school had established comparable policies regarding the administration of physical exams and screenings of students on or before January 8, 2002.

PPRA affords parents the right to consent, receive notice, inspect and opt their child out of activities, physical examination or screening as a condition of attendance, or surveys.

General guidance is located on the United States Department of Education website.

Grievance Process:

Parents who believe their rights have been violated under FERPA or PPRA may work directly with their school, state agency, or file a complaint with the United States Department of Education Student Privacy Policy Office at: https://studentprivacy.ed.gov/file-a-complaint

Delegation

School Nurse delegation nine step process:

The safety and wellbeing of the student is the center focus of all decisions regarding the delegation of nursing tasks. Delegation is used in many professional arenas of employment, to include education and healthcare. 

Nursing delegation in schools is the process of a registered nurse transferring the authority to perform selected nursing tasks or health service delivery in selected situations to a qualified and consenting delegatee. 

Step 1: The school nurse assesses their understanding of the task prior to completing or delegating the task. 

Children come to school with all kinds of ongoing health service needs. A registered nurse who has not performed a task in a long time, practices within their role to maintain accountability and safety. The school nurse protects the student by seeking updated knowledge from other licensed personnel in the specific expertise or healthcare field to ensure the task is proficiently performed correctly in a safe and skilful manner. 

Step 2: The school nurse assesses the learner. 

The school nurse collects data from various sources, to include but not limited to: nursing assessment of the student, the stability of the their health condition, the complexity of the nursing task or activity, the predictability of the outcome from completing the nursing task or activity, Information communicated in collaboration with the family or healthcare provider information if shared by the family, and other resources available to adequately monitor, evaluate and supervise delegated tasks. 

Step 3: The school nurse assesses the nursing task or activity to be delegated. 

The school nurse ensures  the nursing task or activity: is not complex, is part of the student’s routine healthcare,  follows a sequence of steps, does not require assessment if the delegatee is unlicensed, does not require judgement by the unlicensed delegatee,  does not require interpretation by the unlicensed delegatee, does not require modification, has a predictable outcome, is not beyond the ascribed level of practice of the delegatee. 

Step 4: The school nurse ensures delegation is within the right circumstance. 

The school nurse reflects on the communication between the parents, student (if applicable), school nurse and school personnel. The school nurse and parent relationship focuses on the student's access to their education program with a balance of continuity of care within licensed standards of practice.  School nurses respect parents' choices and understand that families may not be aware that nursing tasks performed in the home setting take on a more complex dimension in the school business setting. School nurses and licensed educators are held to the higher regulatory standards when making health service delivery decisions versus a parent or guardian making health service delivery decisions at home to their child.

Step 5: The school nurse identifies the delegatee in the school setting. 

Primary consideration with assignment and delegation is given to the recommendation of the school nurse and consent from the delegatee. The school nurse is required to retain accountability and assess the delegatee’s attributes prior to being compelled to make a decision for delegation. These attributes include, but are not limited to the delegatee’s credentials, education, previous healthcare experience, existing job duties or responsibilities, willingness, ability to follow school guidelines, school policies, school procedures, and capability to follow the communication structure. 

Step 6: The school nurse creates an Individualized Health Plan (IHP) and plans the direction for the nursing task or activity.

The school nurse develops an IHP for ongoing nursing and delegated health service delivery. The school nurse documents the provision of training to the delegatee that includes the delegatee’s consent, the steps of the delegated task, attestation that a skills check was completed annually and evaluation/supervision of the delegate task.

Step 7: The school nurse collaborates and plans a two-way process of communication with the delegatee that includes documentation.

The two-way communication process promotes trust, initiative, appreciation, and willingness to help with ongoing health service delivery to students. Communication also includes timely documentation that is accurate to collaborate with others and provide a record that the task or activity was complete. 

Communication from the school nurse to the delegatee includes student specific characteristics, unexpected observations to report, concerns requiring immediate communication. 

Communication from the delegatee to the school nurse includes asking questions about delegated nursing tasks, seeking clarification prior to performing health services, asking for additional training, additional supervision and complete documentation of care provided.

Step 8: The school nurse determines frequency of supervision, monitoring, and evaluation of the delegatee performing the delegated nursing tasks or health service delivery.  

The school nurse reviews if the delegation was performed correctly and documentation was completed by the delegatee. The school nurse provides feedback and addresses any challenges related to delegation and provides feedback to the delegatee.

Step 9: The school nurse retains accountability to determine frequency of onsite supervision and assessment. 

Unacceptable delegation, revocation of delegation or declination of assignment

An assignment is the provision of nursing care requested from a school district or school administrator to a school nurse that is within the authorized scope of practice for the nurse. 

Delegation is the act of transferring to the delegatee the performance of specific nursing tasks or health service delivery that is beyond the delegatee’s role in the school setting that requires additional training and a hands on skills check.

The school nurse cannot delegate: 

• nursing assessment to an unlicensed delegatee
• formulating nursing diagnoses
• family or patient education
• planning
• supervision, monitoring or evaluation
• nursing judgement
• any nursing activities or functions which are beyond the scope of practice of the licensed practical nurse to an unlicensed delegatee 

The school nurse declines an assignment when the nurse:

• does not have the authority to intervene or take correct action if necessary
• has never performed the health task that is to be supervised, monitored and evaluated
• does not have the opportunity and/or proximity to provide effective monitoring, evaluation, or onsite supervision
• would not be able to intervene if there was a problem

The school nurse may determine not to delegate or revoke delegation with reasons such as: 

• regulatory issues
• failure of the delegatee to demonstrate competency in the nursing task after completion of training
• incomplete demonstration of competency in performing the nursing task by the delegatee when providing health services
• issues with safely provide onsite supervision, monitoring, or evaluation the delegated nursing tasks
• student health status change
• assessment data

Documentation of School Nursing Practice and Health Service Delivery:

The school nurse must ensure that there is a plan for communication and documentation of that plan when nursing practice and health services are provided. This communication plan can be written within training, the individual health plan, the emergency action plan or student health records.

Documentation is required when any health service or nursing task is delegated and whenever a health service or nursing task is performed.

The purpose of documentation (Steps 1 thru 10):

1. Provides evidence of the nurse’s legal responsibility
2. Demonstrates standards, rules, and laws of nursing practice
3. Reflects professional and ethical conduct
4. Supplies information for cost to benefit reduction or reimbursement
5. Furnishes data for quality assurance
6. Protects students, families, school nurse and schools
7. Reflects assessment and care provided to the student
8. Demonstrates the results of treatment provided
9. Helps to plan and coordinate student care
10. Allows interdisciplinary exchange of information about the student

The basic principals of documentation (Steps 1 thru 16):

1. Entries should be legible, written in blue or black ink if paper charting or in an electronic health record
2. Computerized Records [EHR] should be secure and password protected
3. The date and exact time should be included with each entry
4. Should include any nursing action taken in response to a student’s issue
5. Assessment data should include both positive and negative findings
6. All records should be kept current for individual students, no multiple student visit log
7. Include precise measurements, correct spelling, essential information and standard abbreviations
8. Subjective data should be in the student’s own words
9. Objective data should be factual and relevant to the student’s care or clinical nursing judgement provided by the school nurse or as delegated to the paraprofessional
10. Frequency should be ongoing, consistent over time and based on student’s acuity, nursing protocols or school policy
11. Include the reason for the student’s visit
12. The school nurse’s determination using professional nursing judgement
13. The school nurse’s actions taken in response to a student’s problem or the delegated interventions provided by the paraprofessional
14. The outcomes/disposition of the student
15. The nurses name, paraprofessional’s name, credentials (if applicable)
16. The students name, demographic information with 2 identifiers

Documentation errors to avoid and considerations (Steps 1 thru 12): 

1. Avoid failing to document observations or nursing actions. Failure to document produces gaps in the student’s health record suggesting neglect in care.
2. Avoid treating flow sheets for school health services casually. Don’t neglect to record the learner's response to care provided or change in the learner's condition.
3. Avoid altering student health records :
   1. An alteration in the record can make a defensible case, indefensible
4. Consider the importance of documenting in real time.
   1. If a “late entry” is necessary then identify it as such and reference the date and time you are relating back to.
   2. If you need to add additional information to an existing note, then identify the new note as an “addendum” to the date and time
5. Avoid failing to discontinue medication.
   1. School nurses delegate medication, a failure to discontinue a medication can lead to a medication error.
6. Avoid writing Illegibly
7. Avoid documenting personal opinions.
8. Consider recording only:
   1. factual and objective observations
   2. the student’s statements or parent communication to include the inability/reason to not be able to contact a parent
9. Avoid improper corrections.
   1. Never erase or obliterate an error.
   2. Consider correcting an entry, by drawing a singular line thru it, label  it “error”, sign and date
10. Avoid vague or erroneous abbreviations
11. Consider using only standard abbreviations

Three strategies for risk reduction in documentation (Strategies 1 thru 3):

Strategy 1: The school nurse should document full assessment data

1. There are many cases where a nurse fails to document full assessment data leading to accusations of negligence:
2. Document what is not visually assessed, in addition to what is assessed meaning: (e.g. no bruising, swelling, or deformity noted)
3. Nurse documentation should clearly reflect that nurse is monitoring for foreseeable complications
4. Document all communications with the student's parent or healthcare provider: If you placed a call to the parent or if you spoke with the parent in your office, the parking lot, or in a hallway: DOCUMENT IT.
5. If you placed a call to the parent or healthcare provider and there was no answer: DOCUMENT IT.
6. Document your assessment and the student's response to nursing care provided.

Strategy 2: The school nurse or paraprofessional should be precise

1. Be precise in documentation
2. Do not document in advance
3. Always include a date and time
4. Document in the correct student health record
5. Be consistent in your documentation style and method
6. Be factual and avoid:
   1. Labels and unprofessional adjectives, like “appears spaced out” or “acting bizarre”
   2. This hurts your credibility and reflects poorly on your professionalism
7. Avoid assumptions, bias or conclusions, like “the student appears to not have taken her medication this morning at home” or “the parent didn’t take the student to the doctor yesterday after the student was sent home”.

Strategy 3: Documentation and other reports as directed by school districts (e.g. incident and accident reports)

Keep in mind that school incident or accident reports:

1. are "administrative communication”
2. are filed separately from a student’s record
3. are not a substitute for nurses notes or paraprofessional performed interventions
4. nor are nurses notes or paraprofessional documentation a substitute for incident or accident reports
5. can be used as “memory joggers” to document in the student’s health record.
6. used to facilitate decisions about restitution

What is a “memory jogger”?

The United States Department of Education has provided guidance on what records are exempted under FERPA:

“Exempted from the definition of education records are those records which are kept in the sole possession of the maker of the records and are not accessible or revealed to any other person except a temporary substitute for the maker of the records. 

Once the contents or information recorded in sole possession records is disclosed to any party other than a temporary substitute for the maker of the records, those records become education records subject to FERPA. 

Generally sole possession records are of the nature to serve as a “memory jogger” for the creator of the record. 

For example, if a school official has taken notes regarding telephone or face to face conversations, such notes could be sole possession records depending on the nature and content of the notes. 

School nurses many times will provide care away from the environment where documentation can occur immediately. The school nurse may have a "memory jogger" that includes the provision of nursing practice provided to the learner(s) during a crisis or time away from the ability or resources (computer) to document.”

Considerations with memory joggers ( 1 thru 5):

Consideration 1: Never consider recreating a "memory jogger" as a form of documentation to show that health services were performed.

Consideration 2: Dispose of a "memory jogger" once information has been documented in a manner that protects the learner's confidentiality.

Consideration 3: If a school nurse or paraprofessional is going to store memory joggers, they must be kept in the sole possession of the maker of the record and are not accessed or revealed to any other person except a temporary substitute of the maker of the records. 

Consideration 4: Always try to document immediately with the provision of care for quality and safety.

Consideration 5: Do not wait until the end of the day to document.

Drug and Alcohol Testing To Meet Federal Motor Carrier Safety Administration (FMCSA) Requirements: School Transportation

The school administration team may request the school nurse, as licensed health personnel, to attend professional development to complete the drug testing and alcohol testing requirements of licensed school bus drivers to meet the department of transportation [DOT] testing requirements for quarterly,  post-accident, random, and when there is suspicion testing. 

Early Childhood and Preschool Programs (Health Requirements)

Iowa’s school districts and their community partners operating Statewide Voluntary Preschool Programs (SWVPP) and preschool classrooms providing Early Childhood Special Education (ECSE) instructional services are required to demonstrate that the program(s) are meeting one of the three sets of approved preschool program standards that include health requirements. The three standards are:

1. Iowa Quality Preschool Program Standards (IQPPS)
2. Head Start Program Performance Standard
3. National Association for the Education of Young Children (NAEYC)

Health services required for learners who attend school sponsored programs are the responsibility of the school. School nurses are integral in ensuring unlicensed personnel can assist in managing the health needs of the school sponsored programs (IAC 281.14.2).

Evaluator License (School Nurse Standalone) 

The provision of health services and nursing services to learners is a complex activity requiring a set of knowledge, skills, and dispositions from professionally licensed nurses. An effective Iowa school nurse seeks to develop, support, and engage all learners in their developmental capacity and assist in their achievement at high levels of positive health outcomes. Iowa expects that effective school nurses will not only ensure student academic growth, but they will also experience a safe and healthy learning environment through the delivery of safe health services.

School districts with more than one nurse may wish to have a licensed registered nurse evaluate their professional licensed colleague for safe nursing scope and standards of practice. 

The Board of Education Examiners (BOEE) has offered the following guidance. Based on the definitions of Practitioner, The BOEE may issue a standalone evaluator license to someone who has a SPR license.

• A nurse must have their registered nursing license and be in good standing from IBON (3 year license or 2 year license if working under a new license).
• A nurse must have a Statement of Professional Recognition (SPR) and be in good standing with the BOEE (SPR 5 years)
• The nurse may then apply for the evaluator certification course online. The nurse must then maintain certification with the BOEE.
• The nurse will be upheld to not only the minimum standards of practice from the IBON, but also the BOEE.

Based on the definitions of Practitioner BOEE can issue a standalone evaluator license to someone who has a SPR license.

References: 

IAC 272.1 Definitions. Note the definition of a Practitioner.

IAC 284.10 Evaluator Training Program . Number 2 references administrator or practitioner.

IAC 281-83.2 (Chapter 83): Under 256.7(27) Evaluator. 

Field Trips 

Introduction: School Districts, accredited nonpublic schools and programs may have students with health service needs participating in field trips and excursions as part of their education program. Field trips and excursions occur within Iowa, out-of-state, or internationally. School districts and accredited nonpublic schools must follow the regulations related to safe medication administration and delivery of special health services to students requiring ongoing health services, in addition to any other requirements within Section 504 and IDEA (IAC 281.14).

Role of the School Board:  School boards or authorities in charge of a public or accredited school may develop or have adopted a policy for field trips and excursions. The policy allows for the school board or authorities in charge, licensed administrator and licensed nurse to be notified well in advance of the field trip and excursion to ensure licensed educators and healthcare providers meet regulatory requirements of practice for ongoing health service delivery.

Role of School Administration: Field trips require approval from school administrators. Schools have processes for educators to make a request for a field trip. School administrators include the school nurse in the notification at the time of request of field trips (e.g. similar to notifying the Director of Transportation that a bus driver will be needed) to provide adequate time to ensure there is a properly trained, qualified school personnel to administer medications in accordance with school policy and state regulation.  A qualified designated person accompanies children who need medications on field trips, replicating the procedures used in the school building using the every five year training and annual skills check to ensure competency as defined by state regulations regarding medication administration.  

Role of the School Nurse: The school nurse is the licensed health personnel delegating the task of medication administration. The school nurse must understand their Nurse Practice Act and school policy. The school nurse must also understand the Nursing License Compact and how to locate other state Nurse Practice Acts. 

Common Questions and Answers:

1. Question: May an Iowa licensed nurse practice in another state when attending a field trip with a student?

Answer:

2. Question: May an Iowa licensed nurse delegate to an unlicensed person who is attending an out of state field trip with a student?

Answer: 

3. Question: May an Iowa licensed nurse practice and attend an international trip with a student?

Answer: 

4. Question: May an international licensed nurse practice in the state of Iowa while attending a field trip with one of their students?

Answer: 

5. Question: May an out-of-state licensed nurse attending a field trip who is not part of the Nurse Licensure Compact practice in Iowa with one of their students?

Answer: A licensed nurse must hold an Iowa license or a multistate license to practice in the state of Iowa regardless of their employer’s location. See below: 

IAC 655—3.2 Mandatory licensure. 3.2(1) A person who engages in the practice of nursing in the state of Iowa as defined in Iowa Code section 152.1, outside of caring for one’s family, shall have a current Iowa license, whether or not the person’s employer is in Iowa and whether or not the person receives compensation. Any nurse who participates in the care of a patient situated in Iowa, whether that care is provided through telephonic, electronic or in-person means, and regardless of the location of the nurse, must obtain Iowa licensure unless specifically exempted. 

3.2(2) Current Iowa licensure is not mandatory when: 

a. A nurse holds an active multistate license issued by a party state, pursuant to Iowa Code chapter 152E. A nurse who practices nursing in Iowa pursuant to a multistate licensure privilege is subject to the jurisdiction of the board, the courts, and the laws of Iowa.

6. Question: What are the limitations/benefits of the Nurse Licensed Compact (NCL):

Answer: The NLC pertains to Registered Nurse and Licensed Practical Nurse licenses only. An Advanced Registered Nurse Practitioner (ARNP) must hold an individual ARNP license in each state of ARNP practice.

Reference the (NCL site)

Iowa Physicians Order for Scope of Treatment (IPOST)

Children attend school daily with complex healthcare needs that include palliative /or end of life care. School nurses and other healthcare providers ethically respond to parents requests and honor the health care plans developed by the child’s parents and health care providers. 

On Sept. 5, 2019, the Director issued a supervisory order regarding school compliance with physician’s order for scope of treatment. This supervisory order explains to schools that school nurses and other health care providers employed by schools and AEA must comply with physician orders for scope of treatment under Iowa Code chapter 144D ("IPOST"), including when an IPOST contains orders regarding life-sustaining procedures (e.g., an order to not perform CPR or call 911). 

This order also notes that other school personnel may comply with IPOST forms. 

The Declaratory Ruling can be located on the Iowa Department of Education's Administrative Appeal Decisions page: https://appeals.educateiowa.gov/

Decision Number 145 (Book 29) September 2019, in RE: School Compliance with Physician Orders for Scope of Treatment: https://educate.iowa.gov/media/5085/download?inline

Students with an IPOST require an Individualized Health Plan (IHP) for ongoing Special Health Services developed by the licensed school nurse. 

Individual Health Plan (IHP) Development

The student’s continuity of health care from home to school is important to access their education program. The school nurse functions as an integral educational team member to deliver nursing practice and health services to students. The individual health plan (IHP) is tailored to define the ongoing health and nursing services provided when a student is accessing their education program. The IHP is written by a school nurse employed by the school using the components of the nursing process in partnership with the parents, student, healthcare provider, or education team. The IHP follows the student through the course of their educational program, including before and after school-sponsored activities. School nurses develop, review, evaluate, and adjust the IHP through communication with parents, the student, their fellow colleagues or others for a student whose health (stable or unstable) requires the following health service delivery:

• administration of health procedures

• individualized health education

• healthcare intervention or interpretation, to include emergency planning

• use of a health device to compensate for the reduction or loss of a body function 

The purpose of this resource is to provide information to the education team on what is required when using the IHP template as required in regulations, the nursing process, describe the importance of communication with the student or family when developing goals, assigning a domain to the goal or outcome, how to scale a goal or outcome for evaluation and provide best practices in workflow of documentation as outlined in required school policies and procedures.

What is an IHP?

The IHP is an individualized plan developed by the school nurse using the nursing process with effective communication to manage a student’s special health service needs. The IHP follows the student through the course of their educational program. The IHP is defined as:

 “means the documented plan of care utilizing the nursing process as defined in 655—Chapter 6 for evidence-based management of the student’s ongoing special health service in the educational program. The school nurse may develop this plan in collaboration with the education team. The plan also includes a provision for emergencies to provide direction in managing an individual’s health condition (stable or unstable). Documentation of evaluation and updates to the plan are completed as needed and at least annually”.

 (IAC 281.14.2) 

The school nurse, who develops the IHP, works under the auspices of the school and may provide indirect care by delegating nursing tasks and functions to licensed or qualified personnel for students who require health services. This written plan may address delegated health services or how to address emergency needs. The plan must contain the roles and responsibilities of the school, parents, and others in the provision, supply, storage, and maintenance of necessary equipment for health service delivery. The school nurse is responsible for planning, writing, implementing and evaluating the IHP. The school nurse is responsible to monitor, supervise, and evaluate delegated tasks.

 (IAC 281.14.2; IAC 655.6)

General instructions for the IHP template

1. To download and open the fillable template, the school nurse must use the free version of Adobe Acrobat or their student information system if the document is added to their existing system.
2. Read this reference document in its entirety prior to entering information into the template.
3. Remember to always save your work before closing the document.
4. The remaining pages in this reference will include the processes for the development of an IHP.

First Steps When Using the Template: Determining the Pages Needed

The school nurse must first calculate the number of pages needed for interventions to scale out outcomes or goals. Do not enter any information into the template until you have clicked the button on the bottom of page two for the number of pages needed. Please be aware that if the school nurse creates more than one goal, the nurse will also be responsible to evaluate each goal at a minimum annually. 

Second Step: Completing the IHP template

The second step contains the required information, description, and examples of what the nurse will enter into the template.  

Student Identifiers:

The IHP template contains one student identifier and four indirect identifiers that will need to be entered by the school nurse: 

1.  The student’s name (first, last) The student’s date of birth
2. The student’s grade level
3. The student’s school district or accredited nonpublic school
4. The student’s attendance center (building name) 

(United States Department of Education, 2023)

The signature, credentials of the creator, and date of the IHP creation:

The school nurse develops the IHP and signs their name and professional credentials to coincide with the date when the IHP is created.

Date of the Individualized Education Program (IEP) or 504 Plan Review (if applicable):

If the student has a health-related, regular, and ongoing health service in their IEP, the IHP is required and will be uploaded to the state system (ACHIEVE) as a supplement to the IEP. The uploaded plan is updated as needed and evaluated at least annually. The school nurse may enter the IEP review date on the IHP (if applicable).

(Iowa IDEA Information, 2023)

If a student is eligible under Section 504 of the Rehabilitation Act of 1973 (United States Department of Education, 2023), the student’s health services and IHP must be developed under Section 504’s regulations for evaluation, placement, and procedural safeguards. An IHP for a 504-eligible student may not be developed outside Section 504’s requirements. Section 504 teams may determine to attach an existing IHP to a 504 document. The accommodation plan/student progress in a Section 504 plan should be reviewed at least annually and more often upon a review request from the parent, educator, or others. The school nurse may enter the 504-review date on the IHP. 

(United States Department of Education, 2023; Department of Education, 2015)

If a student is not eligible for health services within the federal programs of Individuals with Disabilities Education Act (IDEA) or Section 504, there will be no review date to complete on the template in this section. It is best practice for the school nurse to communicate with the school’s 504 coordinator and special education director annually on the IHPs developed in a building, whenever a substantial change to an IHP occurs, or when a new IHP is created. If the student has an IHP that does not fall under Section 504 or IDEA, the IHP may be kept as an educational record maintained securely by the school nurse in district records or student information systems. School nurses may flag this information in their school’s student information system or work with their technology team for access to streamline this communication with the special education director, 504 coordinator or others with a legitimate educational interest. 

(Iowa IDEA Information, 2023)

Select the Identification of Additional Plans: 

The school nurse may identify on the template if the student has an active IEP or Section 504 plan on the IHP. The school nurse in collaboration with others may determine that the student’s ongoing health service requires an emergency action or evacuation plan to be created or attach an already developed evacuation plan to an IHP. There is a check box section to identify additional plans. School nurses may flag this information in their school’s student information system or work with their technology team for access to streamline this communication with the special education director, 504 coordinator or others with a legitimate educational interest. 

The emergency action plan or emergency evacuation plan is a component of the IHP to address emergency health needs while the student is accessing their education program (IAC 281.14.2). The emergency action plan or emergency evacuation plan is developed to assist unlicensed personnel in addressing emergency care or evacuation for a student with a health condition (stable or unstable) that requires ongoing special health services. The plans follow a series of steps for unlicensed personnel to carry out. If the emergency action is invasive, unlicensed personnel must provide consent. 

The emergency action plan may be created by the school nurse or the student’s health care provider in collaboration with the school nurse who delegates the emergency health service or task to unlicensed or licensed personnel to address the student’s emergent ongoing health service needs. In addition, the emergency evacuation plan may be written by the school nurse or others on the education team familiar with the student to address a student’s health needs to evacuate during and emergency or crisis safely. All unlicensed personnel receive training and demonstrate competency to implement an emergency action or evacuation plan. This training and competency are documented as required in policies for special health services.

Non-Exhaustive Examples: 

Emergency action plan box checked: A student diagnosed with a severe allergy to peanut exposure requires an emergency action plan for anaphylaxis at school. 

Emergency evacuation plan box checked: A student diagnosed with autism with auditory sensory issues requires an emergency evacuation plan when building alarms are activated.

Health Conditions or Other Impairments Impacting Educational Programming:

The school nurse partners with the student’s family regarding the student’s health needs. The school nurse also communicates with the student’s healthcare provider if the family has provided consent. 

The discussion with the student’s family or student includes asking, “what matters most to them regarding the student’s health service delivery and goals at school”. The discussion with family, students or the health care provider is related to the student’s health condition or other impairments (stable or unstable) requiring health service delivery at school to access their education program that includes, but is not limited to, the following: 

• Interpretation or intervention, 

• Administration of health procedures and health care,

•  Use of a health device to compensate for the reduction or loss of a body function

• Emergency services 

(IAC 281.14.2) 

The student’s parents are not required to provide the district or school with health information or medical records regarding their student’s ongoing health needs. The school team may request the parent sign a release of information to communicate with the student’s healthcare provider about information that the parent has specified on the release for making decisions related to education programs. The school team may utilize procedural safeguards to ensure a comprehensive evaluation. 

The education program includes all curricular programs and activities on and off school grounds (IAC 281.14.2). 

Non-Exhaustive Example: Anaphylaxis (Allergen: Peanuts)

Select the Equipment, Roles, Supplies, and Maintenance of Equipment

The school nurse selects a box on the template for equipment, roles, supplies, and maintenance for the school, the parent, or others. 

If “other” is selected, the school nurse is required to complete the text box with a brief explanation. The school nurse checks the required box that the supplies and equipment are secure. 

This is required in Iowa Administrative Code 281.14.2: 

The individual health plan shall designate the roles and responsibilities of the school, parents, and others in the provision, supply, storage, and maintenance of necessary equipment. Parents shall provide the usual equipment, supplies, and necessary maintenance of the equipment unless the school is required to provide the equipment, supplies, and maintenance under the Individuals with Disabilities Education Act and 281—Chapter 41 or Section 504 of the Rehabilitation Act of 1973. Schools must store equipment in a secure area.

“Other Box” Non-Exhaustive Examples:

Other: The school will supply the lift device, changing table and privacy screen. The parents will supply the wipes and briefs for the student’s hygiene care. 

Other: The school will supply the communication board and lift device. The parents will supply the student’s wheelchair, orthotics, gastric tube supplies and enteral nutrition.

Summary of Health Concerns and Other Essential Information

The summary of health concerns and other information is a text box on the template for the school nurse to enter information related to the student’s health conditions, other impairments, and include the identified health needs that the student will need during the school day for the current school year. 

The school nurse shares information in the “Summary of Health Concerns and Other Essential Information” with teams in the context of the IDEA, Section 504, or others with a legitimate educational interest.

The content in this box may include specific nursing tasks provided by the nurse or delegated to unlicensed or licensed personnel, use of a health device, other relevant information needed for the education team. It may also include functions performed by a registered or licensed nurse for the student to access their program in management of their health condition or other impairment (stable or unstable) supported by existing documentation already required in the school’s policies or procedures. 

Non-exhaustive examples of dialogue in a “Summary of Health Concern and Other Essential Information” box:

 “The student has an IEP and health is not identified in the PLAAFP (present level of academic achievement and functional performance). The student requires emergency medication management as outlined in the EAP, provider information, and MAR (medication administration record) during the school year to address the ongoing health service needs for the student's diagnosis of anaphylaxis. The school nurse and parents identified that the parents would like the school nurse to assist the student in identifying the allergen, a source that could result in exposure, and a way to prevent exposure.” 

“The student has an IEP and health is identified in the PLAAFP. The student requires medication management as outlined on information provided by the provider and additional forms per policy and procedure during the school year to address the ongoing health service needs for the student's nursing and health service needs for autism and asthma. The student requires a 1:1 associate throughout the day for safety, transitioning, toileting, hygiene and implementation of the EAP/EEP. The school nurse and parents identified that the parents would like the school nurse to assist the student in identifying a trigger for their asthma and one way to communicate when the student is having respiratory difficulty.”

“The student requires a 1:1 paraprofessional to assist with performing ADLs, safety, implementation of delegated tasks and emergency plans”

Nursing Assessment and Planning

The school nurse checks the appropriate boxes to indicate what data was used in the assessment step of the nursing process (IAC 655.6; IAC 281.14.2).

The nursing assessment and planning area of the IHP is where the school nurse utilizes information provided in communication with the student, family, or healthcare provider and selects what data is used to develop the IHP. Data may include student observation, nursing assessment, communication with the student’s family, data gleaned from registration or consents received for the delivery of school health services, copies of medical records provided to the school by parents that are then protected as educational records (if applicable), and more. 

The school nurse may utilize the “Special Health Care Needs Assessment” template to organize assessment data within their licensed practice and as an integral team member for considerations related to the level of care determination made by education program teams using professional nursing scope and standards of practice (Iowa Board of Nursing IAC 655.6; Iowa Department of Education, 2023).

The assessment and planning component of the IHP also provides an opportunity to develop a trusting partnership in the initial conversation with the family or student to:

• acknowledge the student and/or family as the expert in the student’s health, 

• provide an opportunity for the school nurse to understand the unique history or circumstances requiring the student’s need for ongoing nursing or health services at school, the family’s culture, customs and beliefs in accessing healthcare 

• ask the student or family “what matters most” in achieving a health goal that can then be used as a student-centered metric for evaluating their received school health service delivery.

Three Best Practice Tips for Nursing Assessment and Planning in IHP Development:

1. Ask the student or students family, “what matters most in the student’s health service delivery and goal development” while at school. The communication the school nurse has with a student and their family is empowering. The communication may lead the student to actively participate in their health and healthcare delivery.
   
   Important Points to Remember:
   1. The school nurse can use interactions with and families to discuss student-centered care in a culturally congruent manner. Health beliefs, religious beliefs, health customs, ethnic customs, dietary customs and interpersonal customs are a few examples that can influence how students or their families interact with the school nurse (United States Health and Human Services, 2023).
   2. Also, the student or parents may need more time to answer on what matters most or might not be interested in setting a goal at the time that the school nurse asks the question. This response is okay. They may need additional time to think about this question.
2. Set up a process within the school’s information system or health service delivery documentation to alert the school nurse of students or parents whom the school nurse has not communicated or connected with in developing the student’s IHP (if applicable).
3. Set up a procedure within the school’s information system or health service delivery documentation to alert the school team or school leaders about a student’s IHP, including developed emergency action plans (EAPs) or emergency evacuation plans (EEPs).

Non-Exhaustive Example: Download or flag these three in the school’s student information system or school health documentation at the local school level to share with individuals who hold a legitimate educational interest. 

Nursing Diagnosis:

The school nurse clicks the drop-down box on the IHP template to select the nursing diagnosis type and uses the text box to write the nursing diagnosis chosen for the IHP.

The nursing diagnosis in an IHP is a clinical judgment concerning a student’s response to a health condition or life process (IAC 655.6). It is a distinct step in the nursing process and a requirement for developing an IHP (IAC 281.14.2; IAC 655.6). The nursing diagnosis is not to be confused with a medical diagnosis. A medical diagnosis focuses on disease and pathology from the student’s prescribing healthcare provider. In contrast, a nursing diagnosis is the label provided when the licensed school nurse who the school employs assigns meaning to collect data in the nursing assessment that focuses on the human response of all health services provided to the student at school.

There are four types of nursing diagnoses:

1. Problem-Focused Nursing Diagnosis: A problem-focused nursing diagnosis has three parts: This type of nursing diagnosis contains the nursing diagnosis, related factors, and defining characteristics.
2. Risk Nursing Diagnosis: A risk nursing diagnosis has two parts. The nursing diagnosis includes a risk diagnostic label and risk factors. This diagnosis uses a clinical nursing judgment that a problem does not exist. However, the presence of risk factors indicates that a problem will likely develop unless the licensed nurse intervenes. The school nurse utilizes assessment information from the student’s current health status, past health history, and other risk factors that may increase the likelihood that a student will experience a health problem at school.
3. Health Promotion Nursing Diagnosis: A health promotion diagnosis has two parts. The nursing diagnosis includes a readiness statement that identifies a student's readiness to engage in activities to promote health and wellbeing. A health promotion diagnosis is a clinical nursing judgment about the motivation and desire of the student to increase wellbeing that guides nursing intervention to support the student's learning.
4. Syndrome Diagnosis: A syndrome diagnosis is one statement in the diagnosis label. The syndrome nursing diagnosis is a clinical judgment concerning a cluster of problems or risk nursing diagnosis predicted to be present because of a particular situation or event.

Nurses who want standardized nursing diagnosis examples can access the North American Nursing Diagnosis Association International (NANDA-I) resources, which refine taxonomy structure through domains, classes, and diagnoses.

(North American Nursing Diagnosis Association International [NANDA-I], 2023)

Nursing or Delegated Health Service Intervention

A parenthesis is located in the IHP template that provides language to “see additional forms per policy or procedure” to prevent duplicative documentation of school health service delivery. Please see nonexhaustive examples of additional forms and supporting documentation in the “Summary of Health Concerns and Other Essential Information”:

Non-exhaustive examples of supporting documentation and forms referred to in the “See additional forms per policy and procedure” box: 

Instructions from a community provider that is given to the school nurse from the student’s parents used to treat or coordinate care of a student’s specific health condition or issue while at school, consent from parents for the administration of medication and health service delivery, medication administration records, consent from unlicensed personnel to perform invasive delegated nonemergency health tasks, training and competency documentation of school personnel with delegated tasks, and required documentation for nursing and health service delivery encounters and services.

Non-Exhaustive Examples of Documentation Under Intervention(s): 

Dependent Intervention: The student requires prescribed medication administration as outlined by the healthcare provider during the (specified) school year. 

Independent Intervention: The student will acquire a skill necessary to manage their diabetes independently with education provided by the school nurse by the end of the (specified) semester.

Collaborative Intervention: The student has an emergency action plan for delegated diabetes management that will be carried out by qualified personnel in the event of an emergency during the (specified) school year.

A combination of all intervention types: The student requires health service delivery and nursing practice during the (specified) school year.  

Nursing-Led Outcomes or Student-Led Goals

Nursing-led outcomes or student-led goals are created during the communication step with parents and the student along with the planning step for implementing nursing practice or health service intervention, either through direct care, education provided by the nurse, or in-direct care through delegation of health services to qualified or licensed school personnel by the school nurse. 

The school nurse’s primary commitment is to the student and their families in nursing practice and health service delivery. The school nurse delivers care to promote and preserve student autonomy, dignity, and rights. To foster an environment conducive to individualized health services and culturally congruent care, the school nurse develops a supportive and trusting partnership with the student and their family (National Association of School Nurses, 2023; National Association of State School Nurse Consultants, 2023). The foundation of this partnership begins with effective communication and assists in determining student-led health goals (if applicable). Also, the school nurse acknowledges social determinants of health that can affect a wide range of student’s health, functioning, and quality-of-life outcomes and risks (Office of Disease Prevention and Health Promotion, n.d.). Student-led goals developed in collaboration with the student or family promote engagement and empowerment with students acquiring the skills necessary for independence in managing their health or maintaining a safe learning environment.

The school nurse also fosters a supportive partnership with the school team or the student's healthcare provider. The school nurse provides indirect care through delegating nursing tasks and functions to qualified personnel, who are equipped with the knowledge and competency to deliver health services to maintain a student’s current level of health in a safe environment or as the student acquires skills to independently manage their health needs as outlined in the goals. The school nurse supervises, monitors, and evaluates delegated nursing and health service delivery (IAC 281.14.2; IAC 655.6).

Nursing-led outcomes or student-led goals encourage communication, collaboration, and, most importantly, student or family involvement. Nursing-led outcome measurement provides objective evaluation data related to the healthcare delivery process and meets the evaluation requirement in a specific, measurable, attainable, realistic and time sensitive way (IAC 241.14.2; IAC 655.6). Student-led goal setting is done through communication with students or families to define and agree on expected levels of achievement written in a specific, measurable, attainable, realistic and time sensitive way to address health service delivery and possibly post-secondary health expectations (if applicable). The 11 Iowa Schools: Individual Health Plan Template Reference Document school nurse utilizes the communicative partnership to discover what matters most with families and students in terms of goals and outcomes when:

• developing the IHP,
• adding or changing interventions and
• evaluating or changing student-led goals or nursing-led outcomes.

Importance Rating Scale

The school nurse selects an answer in the template under the importance rating scale of the goal or outcome with active communication from the student or family.

An essential component of writing a nursing-led outcome or a student-led goal is establishing meaningful criteria for a successful outcome that is student-centered, which should be agreed upon with the student or family before an intervention associated with the goal starts so that everyone has a realistic expectation of what will likely be achieved and the student and family agrees that the goal is worth striving for.

The best practice would be for the school nurse to communicate with the parent and student (if applicable) on the importance rating scale as it relates to their goal attainment scale when the IHP is developed, when there is a change to an IHP intervention, and whenever the school nurse completes the evaluation. 

The school nurse communicates effectively in all practice areas with the student, parents, provider, or school personnel (NASN, 2023). The communication between the school nurse and the student or student’s parent may happen in many formats but is not limited to in-person, telephonic, written, or electronic format. Parents or students are encouraged to participate in the IHP development. 

Goal-setting discussions and determining the importance rating are most successful when the student or family has a trusting partnership with the nurse. School nurses who are communicating with the student or parents can actively listen for cues that indicate a readiness to set goals, such as excitement about a topic related to skill or health knowledge acquisition, comments related to cultural beliefs and practices, reflections on the past experience with healthcare, and the beginning of identifying possible post-secondary healthcare expectations. 

Students and families tend to speak about what is essential in their lives, including their goals in a results-oriented process that is focused on assisting the student’s movement from school to post-school living, learning, and working environments (Iowa Department of Education, 2023; National Committee for Quality Assurance, 2023).

The following are five questions for the school nurse and student or family to consider when determining importance: 

• Can the student manage their health needs on their own?
• Can the student make health decisions safely?
• Does the student have the basic understanding of medical terms and procedural skills acquisition to manage their own healthcare needs at school or home?
• What additional skills does the student or family envision the student needing for safety at school, in the community, on their post-secondary path, or in adulthood?
• Are there cultural belief and practice considerations?

Difficulty Rating Scale 

The school nurse selects a measure on the difficult rating scale in the IHP template.

An essential component of developing an attainable goal is considering the anticipated difficulty of achieving the goal. The difficulty rating scale is completed with the family, student, school nurse, or qualified personnel (if applicable). The school nurse, with qualified personnel (if applicable), will complete the scale if this is attainment for a nursing-led goal. The student or family should complete scoring this scale in communication with the school nurse if this is attainment for a student-led goal.

Remember that, in effect, if a student-led goal is “not at all important” or “not at all difficult,” it is presumably already achieved. The importance of rating difficulty is in communication with the student or the family to involve them in prioritizing, developing, and possibly identifying specific, measurable, attainable, realistic, and time-sensitive goals or post-secondary health expectations (if applicable).

Likewise, the school nurse needs to have continual communication with qualified personnel about difficulty with delegated tasks and nursing functions as part of the delegation process in evaluating nursing-led outcomes (Iowa Board of Nursing. 2021). The school nurse communicates in their supervision, monitoring, and evaluation of delegation when they transfer accountability to qualified school personnel to safely perform a specific task or activity related to outcomes.

Nursing-Led Outcomes: 

The school nurse identifies expected outcomes for the plan that are individualized to the interventions provided to the student by the school nurse or delegated to qualified personnel (including services provided in an emergency) as described in the associated documentation related to school district policies or procedures. The outcome measures are the desired result of the intervention(s) provided to the student. The nursing-led outcome that the school nurse develops is communicated with the student, family, or education team (if applicable). The nursing-led outcomes are ambitiously attainable and are individualized to the student. Nursing-led outcomes should be specific, measurable, attainable, realistic, and time-based (SMART). The nursing-led outcomes associated with delegated tasks provided by qualified personnel are supported by existing documentation that aligns with school policy and procedures.

Non-Exhaustive Example of a Nursing-Led Outcome

The student will experience no injury related to medication management or implementation of the EAP for anaphylaxis management provided by qualified personnel during the (selected evaluation time frame).

Student-Led Goals: 

Student-led goals are developed to be intrinsically motivating and inherently rewarding to the student and address student choice in developing independent skills to improve health outcomes (Orsini, Evans, and Jerez, 2015). School nurses discover what matters to the student and their families about managing the student’s health through partnership, assessment, and communication. Student-led goals strive to improve learning and performance in completing health needs. Health behavior change research suggests that a challenging goal that is intrinsically motivating to an individual or an individual’s family is beneficial (National Committee of Quality Assurance, 2023). 

A school nurse, the student, or the student’s family must also consider self-efficacy and the student’s confidence in one’s ability to achieve a specific goal. Setting and achieving challenging goals can enhance self-efficacy. Repeated failure to achieve a goal can result in diminished self-efficacy, decreased satisfaction, and impaired future performance. Consideration of repeated failure to successfully perform a task can lead to complete nonperformance of a task.  

A school nurse, the student, or the student’s family must also consider self-efficacy and the student’s confidence in one’s ability to achieve a specific goal. Setting and achieving challenging goals can enhance self-efficacy. Repeated failure to achieve a goal can result in diminished self-efficacy, decreased satisfaction, and impaired future performance. Consideration of repeated failure to successfully perform a task can lead to complete nonperformance of a task.  

Lastly, school nurses need to communicate nursing practice using inclusion principles that promote the practice of cultural competency. Health literacy is a non-exhaustive communication aspect of culturally congruent healthcare (School Nursing Scope and Standards, 2023). 

When formulating a student-led goal for an IHP, the goal should be:

• meaningful to the student and the student’s family
• addresses cultural beliefs and practices
• ambitiously attainable
• written to prepare the student for the school-to-adult life transition, if applicable
• general statements that focus on deficits in health-related knowledge or skills competency
• in health literate language that is easily understood by the educational team, student, or student’s family
• written to increase the student’s successful participation in the general education setting and allow for inclusion in the general education environment to the maximum extent appropriate with peers

Non-Exhaustive Student-led Goal Example: 

The student will identify 1 trigger and 1 preventative skill (handwashing) associated with anaphylaxis during the (specified) school year

Selecting a Goal Domain

The school nurse selects a goal domain on the IHP template.

Goals that are developed in an IHP can fall into domains of student-centered outcome measures that the school nurse or leadership team can use in measuring performance in monitoring the quality of school health service delivery, coordination of care, services, and support in school health services. The health plan is individualized to the student and developed by the school nurse in partnership with the family and others. A student’s individualized health plan goal may reflect social determinants of the student’s health that involve holistic quality of life domains that are impacted outside of the traditional school setting (United States Department of Health and Human Services, 2023; NCQA, 2024). 

Likewise, a goal may include achieving health and wellbeing in partnership between the student, family, school nurse, and other licensed providers and clinicians within the school setting or school community. The school nurse selects the domain that aligns with the goal or outcome written in the IHP. Below is the list and definitions of the student-centered outcome domains provided by the National Committee for Quality Assurance that are located in the IHP template (2024). 

Based on an extensive review of goals, listed are the most common domains that can be used in  goal attainment to highlight support, monitoring, coordination or identify barriers (student):

1. Medication Management: Goals focused on the ability to manage medications.
2. Improving Health and Wellness: Goals related to developing, improving and maintaining positive health and wellness habits.
3. Managing Conditions and Symptoms: Goals related to health care received or desired and to experiences with providers and the health care system.
4. Access to Services and Supports: Goals focused on the ability to access, afford, and utilize appropriate health and community resources including access to transportation, stable food resources, assistance with financial concerns.
5. Physical Function: Goals related to managing physical functioning, physical symptoms or conditions and improving or maintaining the ability to participate in physical activities.
6. Social and Role Function: Goals focused on engaging in meaningful activity like work, hobbies, or social interaction with family and friends.
7. Emotional and Mental Health: Goals related to managing mental health symptoms or participating in activities that impact emotional aspects of quality of life.
8. Legal: Goals related to legal issues or legal involvement.
9. End of Life: Goals related to end-of-life care and desires.
10. Housing: Goals related to individuals’ place of residence.
11. Caregiver Needs and Concerns: Goals expressed by and for caregivers that focus on caregiving responsibilities and skills, finding respite care, and receiving social support.
12. Independence: Goals that center on living one’s life independently without help or assistance from others. 

Last Step: Goal Attainment Scaling to Define Measurable Evaluation

Each goal is evaluated on a five-point scale, with a degree for capturing attainment measures in evaluation. The school nurse completes the goal attainment scale in collaboration and communication with the student, family, or education team (if applicable). 

Below will define how to scale out a goal from the dependent, independent, collaborative or combination of the three types of intervention with non-exhaustive examples:

Zero (0) Achieves or Maintains

The evaluation score of zero is applied if the result of providing an intervention is to achieve maintenance or maintain the expected level of the outcome as defined in the nursing-led or student-led goal. 

Instructions: The school nurse takes the SMART goal (Specific, Measurable, Attainable, Realistic, Time-based) listed in the nursing-led outcomes/student-led goal line and pastes it into the zero line of the scale.

Non-Exhaustive Examples: 

Nursing-led outcome: The student will not require the use of the EAP for anaphylaxis management by the school nurse or qualified personnel during the (specified) school year. 

Student-led goal: The student will verbally identify one allergen exposure that would result in anaphylaxis (requiring the initiation of the EAP) during the (specified) school year. 

Somewhat Better (+1)

The evaluation score of +1 is applied if the results of the nursing intervention or student achievement in skills acquisition have a better-than-expected outcome as defined in the nursing-led outcome or student-led goal.

Instructions: The school nurse uses the SMART goal outlined in Zero and makes it somewhat better either through a measurement of intervention, gain in skill, or time. 

Non-Exhaustive Examples: 

Nursing-led outcome: The school nurse identified one potential environmental trigger for the student in the school environment that may have resulted in anaphylaxis and the student did not require the use of the EAP during the (specified) school year by the school nurse or qualified personnel. 

Student-led goal: The student verbally identified one allergen exposure that would result in anaphylaxis (require the initiation of the EAP) and verbalized one skill (handwashing) to address the prevention of anaphylaxis during the (specified) school year.

Much better (+2)

The evaluation score of +2 is applied if the results of the nursing intervention or student achievement in skills acquisition have a much better outcome as defined in the nursing-led outcome or student-led goal.

Instructions: The school nurse uses the SMART goal outlined in "Somewhat Better +1” and makes it somewhat better either through a measurement of intervention, gain in skill, or time. 

Non-Exhaustive Examples: 

Nursing-led outcome: The school nurse developed a procedure for personnel or students to report potential allergens in the school environment that may result in the student experiencing anaphylaxis and the student did not require the use of the EAP during the (specified) school year by the school nurse or qualified personnel. 

Student-led goal: The student verbally identified one allergen exposure that would require the initiation of the EAP, one source of the allergen, verbalized and demonstrated one skill (handwashing) to address prevention of anaphylaxis during the (specified) school year.

Somewhat Worse or Current State (-1): 

The evaluation score of -1 is applied if the results of the nursing intervention or student achievement in skills acquisition has a somewhat worse outcome as defined in the nursing-led outcome or student-led goal. This is also the current state or baseline prior to any intervention provided.

Instructions: The school nurse uses the SMART goal outlined in "Zero Achieves or Maintains” and utilizes the student’s current state in the SMART format or creates a SMART goal that is less than zero through a measurement of intervention, gain in skill, or time. 

Non-Exhaustive Examples: 

Nursing-led outcome: The student experienced anaphylaxis at school and required the school nurse or qualified personnel to use the EAP during the (specified) school year. 

Student-led goal: The student is unable to identify one allergen that would result in anaphylaxis and the initiation of the EAP to address their anaphylaxis management during the (specified) school year. 

Much Worse (-2)

The evaluation score of -2 is applied if the results of the nursing intervention or student achievement in skills acquisition have a much worse outcome as defined in the nursing-led outcome or student-led goal.

Instructions: The school nurse uses the SMART goal outlined in "Somewhat Worse -1” and creates a SMART goal that is less than the goal written in “Somewhat Worse -1” through a measurement of intervention, gain in skill, or time. 

Non-Exhaustive Examples: 

Nursing-led outcome: The student experienced anaphylaxis from an exposure at school requiring the use of the EAP twice by the school nurse or qualified personnel, resulting in the student being transferred to the hospital each time during the (specified) school year. 

Student-led goal: The student is unable to identify one allergen and was exposed at school, resulting in the initiation of the EAP and transfer to the hospital to address their anaphylaxis during the (specified) school year.

What is the Baseline Evaluation?

A baseline evaluation score of a negative one has been set before any intervention is delivered for either a student-led goal or a nursing-led outcome, as outlined in the IHP. The baseline is a -1 because the intervention has not been provided to either meet evaluation purposes for maintenance of safety or goal achievement.

Select An Evaluation Timeline 

The school nurse selects the timeframe chosen on the template to complete the evaluation.

The school nurse must evaluate annually, at a minimum per administrative rule IAC 281.14.2 and policy. 

The school nurse collaborates with the student, family, or education team to determine the schedule of evaluation by month, quarter, semester, or annually and selects this on the template. Each evaluation is another opportunity for the school nurse to communicate with the family or student regarding student-led goal progression, social determinants or barriers, changes, or goal setting (if applicable).

Revision to Components of the IHP

Revisions can be made at any time to the IHP template. The student's health needs may have changed and what matters most to the student or their family may have changed. To make a change to the IHP, the school nurse would document a visit note that identifies what the current goal is, the conversation and family or student engagement that resulted in the change and the new goal. 

Instruction: The school nurse changes the SMART goal on page 2 of the IHP template and rescales the SMART goal.

The following are questions when considering a revision to the IHP: 

• Did anything unanticipated occur (e.g., illness, hospitalization, trauma)?
• Has the student’s health condition changed?
• Are the goals or outcomes realistic and ambitiously attainable?
• Are the student-led interventions appropriately focused on supporting knowledge and skill attainment?
• What barriers is the student or nurse experiencing?
• Does ongoing assessment data indicate a need to revise the nursing diagnoses, planned interventions, or implementation strategies?
• Are different interventions required? 

IHP Component: Emergency Action Plan

The school nurse develops individual health plans and emergency action plans for students who may experience life-threatening emergencies related to their health and makes them available to appropriate staff at all times. The child’s healthcare provider can also provide the parents an emergency action plan to provide to the school. Examples include action plans for(noninclusive list):

• Diabetes
• Asthma
• Anaphylaxis
• Adrenal Crisis
• Sickle Cell Crisis
• Cardiac Event
• Seizure Disorder

Steps for the School Nurse to complete the EAP:

• Complete the student demographic information and identifiers: Last name, First name, date of birth
• Document the student’s building, district or school, and select their grade from the drop down on the EAP template.
• Type in the EAP school nurse creator’s name and credentials and select the date or type in the date in a xx/xx/xx format.
• In the Team section, identified EAP Team Members and Roles: The team is also identified in the EAP. List the employee(s) names and their roles who are responsible for implementing the EAP.
• Document the medical diagnosis or health related issue that requires an emergency action plan.
• Document what signs or symptoms the trained paraprofessional or school nurse would see or the student would report that would initiate the interventions.
• Document what interventions the trained professional or school nurse would do.

IHP Component: Emergency Evacuation Plan (Steps 1 thru 5) 

Health conditions, utilization of mobility devices, school environment, communication and sensory issues may put students at risk for special evacuation needs (noninclusive list): 

• Utilization of mobility devices
• Temporarily on crutches/walking casts
• Unable or have difficulty walking up or down stairs
• Safety risk related to sensory stimulation issues
• Vision impairments
• Hearing impairments
• Processing disorders
• Limited English Proficiency
• Behavior or developmental disorders
• Emotional or brain health issues

The school nurse develops individualized health plans and either the school nurse or a member of the education team develops the emergency evacuation plans for students who may need assistance with emergency evacuation related to their health  and makes them available to appropriate staff at all times.Steps to complete the EEP. It is the responsibility of the education team to notify the EEP creator if the roles change or additional personnel require training for students requiring emergency evacuation plans as a component of the Individual Health Plan (IHP) for natural or man-made disasters, hazardous conditions, drills or as indicated by school policy. 

1. Complete the student demographic information and identifiers: Last name, First name, date of birth
2. Document the student’s building, district or school, and select their grade from the drop down on the EEP template.
3. Type in the EEP creator’s name and credentials(if applicable) and select the date or type in the date in a xx/xx/xx format.
4. In the Team section, identified EEP Team Members and Roles: The team is also identified in the EEP. List the employee(s) names and their roles who are responsible for implementing the EEP.
5. Dependent on the facility type, Bus or other needs, type in the steps or interventions that will be used for safe evacuation. 

Influenza and Respiratory Disease Absenteeism Voluntary Reporting

Iowa HHS works with Iowa school nurses, the Iowa Department of Education, and local public health entities to track and respond to reports of influenza (flu) and other illnesses in schools. This is done through two main systems: weekly illness and daily 10% illness. 

Daily student absence due to illness of 10% or greater

Schools are asked to voluntarily report absenteeism when 10% or more of the total enrollment is absent on any given day due to illness in a building utilizing the link that is shared out with school nurses at the beginning of the school year and through the Iowa HHS website.

Weekly school absence reporting

Iowa HHS schools also request schools to voluntarily report the number of ill students each week. Schools may submit the aggregate number once a week regardless of the percentage of illness that week through the Iowa HHS website.

Mandatory Reporter Training

School nurses are required to report suspected child or dependent adult abuse to the department of human services. The required training is located on the Iowa Health and Human Services website. The link can be found on the Link addendum to this document. 

Medicaid Presumptive Eligibility

Children and learners attending public school, private school, charter school, preschool programs, and childcare programs may need healthcare and not have insurance to seek the appropriate care. School nurses can assist families with accessing the necessary application to access Iowa’s medicaid program.

Medicaid Qualified Entity (QE) 

The school nurse, in a Medicaid approved provider school (meaning a school that holds a national provider identifier), may become a QE to make the presumptive determination about a child's Medicaid eligibility based on the family's income self declaration statement to assist the child in receiving immediate medical care from a community or school based health center licensed healthcare provider.

Once registered as a Qualified Entity (QE), the QE ensures with their organization that emails from HHS will not be blocked by their organization's firewall. Emails will be the primary source of communications between the QEs and HHS.

Presumptive eligibility (PE) 

Presumptive eligibility provides Medicaid for a limited time while a formal Medicaid eligibility determination is being made by the Iowa Department of Health and Human Services (HHS). The goal of the presumptive eligibility process is to offer immediate health care coverage to people likely to be Medicaid eligible, before there has been a full Medicaid determination. Based on a household’s statements regarding their circumstances and income, a qualified entity (QE) can enter the applicant’s information into the Medicaid Presumptive Eligibility Portal (MPEP). If determined to be eligible, the applicant will have temporary Medicaid eligibility during the presumptive eligibility period. A “qualified entity” or QE is generally defined as an enrolled Iowa Medicaid provider who is certified by HHS and is authorized to make presumptive eligibility determinations. A provider who meets the QE requirements must agree to the terms and conditions in an electronically maintained Memorandum of Understanding (MOU).

Presumptive Eligibility refers to a government program that offers immediate health services access by providing temporary health insurance through Medicaid or Children’s Health Insurance Program (CHIP). A presumptive provider is an organization that approves PE determinations, is authorized by the state agency and who may not delegate their PE authority to another entity, subcontractor or agent. In the state of Iowa, Iowa HHS is considered the presumptive provider. A qualified entity (QE) is an individual authorized to determine presumptive eligibility under the supervision and authority of the presumptive provider. 

School nurses who would like to become a QE should reach out to their school leadership and Iowa Health and Human Services.

Student Health Conditions (Complex Disease Management)

Children living with chronic health conditions go to school every day.  Districts and accredited nonpublic schools must provide services to meet your child's health needs by following rules surrounding the safe delivery of health services.

Care Coordination

The following resources assist safe health service delivery to students by school nurses. Parents, the child’s healthcare provider and school nurse are a team working together to meet the needs of children with chronic health conditions. School nurses perform care coordination in the development and implementation of an individualized health plan, plan for emergencies, communication, working with others in the school setting to ensure the learner’s needs are met and connecting families to community resources.

Standards of Practice

The nursing scope of practice defines the who, what, where, when, why, and how of nursing activities occurring at school. In management of chronic health conditions, the school nurse uses these competencies and expectations for ensuring the provision of high-quality, safe, and ethical care.

Asthma

Learners with asthma (whose condition is stable or unstable) requiring ongoing health services or emergency planning at school or in their program will have an individualized health plan. The following are resources that the school nurse may use: 

Asthma-Friendly Schools Initiative Resources and Tools (American Lung Association)

Managing Asthma in Schools (CDC)

IHP (form link)

EAP (Form link)

EEP (form link)

Anaphylaxis

Learners with anaphylaxis (whose condition is stable or unstable) requiring ongoing health services or emergency planning at school or in their program will have an individualized health plan. The following are resources that the school nurse may use: 

Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs (U.S. Centers for Disease Control and Prevention (CDC))

Diet Modification Request Form

Food Allergy and Research Education (FARE)

IHP (form link)

EAP (Form link)

EEP (form link)

Seizure Disorders

Learners with seizure disorders (whose condition is stable or unstable) requiring ongoing health services or emergency planning at school or in their program will have an individualized health plan. The following are resources that the school nurse may use: 

Epilepsy Learning Portal (Epilepsy Foundation)

IHP (form link)

EAP (Form link)

EEP (form link)

Diabetes

Learners with diabetes (whose condition is stable or unstable) requiring ongoing health services or emergency planning at school or in their program will have an individualized health plan. The following are resources that the school nurse may use: 

Managing Diabetes at School (Centers for Disease Control and Prevention)

IHP (form link)

EAP (Form link)

EEP (form link)

Mental Health 

Learners with mental health conditions (whose condition is stable or unstable) requiring ongoing health services or emergency planning at school or in their program will have an individualized health plan. The following are resources that the school nurse may use: 

Mental Health webpage (Iowa Department of Education)

Your Life Iowa

National Alliance of Mental Illness (NAMI)

NAMI Iowa

IHP (form link)

EAP (Form link)

EEP (form link)