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 required by licensed practice and policy. The school nurse may select one or all three of the check boxes.

The check boxes include:

• learner observation, parent/learner communication
• Information from community, agencies or other sources
• Review of school records (to include medical records, if applicable)

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” form 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.

The assessment and planning component of the IHP also provides an opportunity for the school nurse 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 their child’s health, 

• provide an opportunity 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. Begin the conversation and ask the student or 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 to the student actively participating in their health and school 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.
   2. Also, remember that 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 SIS 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 from the health information received during registration (if applicable).
3. Set up a procedure within the SIS or health service delivery documentation to alert the school team or school leaders about a student’s IHP, including developed emergency action plans (EAPs), emergency evacuation plans (EEPs), or 504 plans.

Non-Exhaustive Example: Download or flag the IHP, EAP, EEP, and 504 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. 

The school may streamline communication by building in the “Special Health Care Needs Assessment” form into the SIS (if applicable) and privacy is set locally by the school. For example, a school may share this built in form with privacy set to share with the Special Education Director or Lead to be completed by their request of the school nurse. Once completed, the form is immediately available to the Special Education Director or Lead.