Long Term Maintenance and Archiving of School Nursing Records

History
Long-term preservation of student health information is imperative in maintaining and improving student health outcomes. Historically, documentation has been critical to school nurses, school districts and other employers against malpractice claims. (NASN, 1998).

Description of Issue
A variety of health information is collected and maintained by a local education agency. Policies and procedures should be established to address purging, destruction and long-term retention of records. Policies should address the various formats of health information including written and electronic records.

Rationale
Local Education Agencies (LEA’s) are responsible for developing policies concerning retention and destruction of records including school health records. These policies are subject to state guidelines and recommendations. The school health records will be maintained for at least the period of the statute of limitations in North Carolina. (Guidance is provided in North Carolina Records Retention and Disposition Schedule for LEA’s. Feb. 1999).

Conclusion
It is the position of School Nurse Association of North Carolina (SNANC) that school nurses ensure an LEA records policy exists for long-term maintenance /archiving of essential student health records. If an LEA policy does not exist, it is recommended that the school nurse support in the development of a Health Record policy and procedures (NASN, 2004). The policy should address the following 3 types of school health information:

1. Records regarded as permanent information: archive and retain indefinitely
   Examples of this information includes, but is not limited to, the following:
   
   • Student Permanent Health Record
   • The student’s health status at the time of school enrollment or transfer, including immunization record
   • Results of screening evaluations, identified health problems, and plan(s) for nursing care or other interventions(s)
   • Notation of teacher/nurse conferences
   • Documentation of referrals for health care
   • Final disposition of referrals including results
   • Notation of parent/guardian contacts
   • Diagnostic and summary reports from outside providers
   • Kindergarten Health Assessment form; retain through elementary school unless it is the only doctor-signed, clinic-stamped immunization record, in which case, retain permanently
2. Records that document care provided, which are of concern while student is in the system and during the NC statute of limitations (for possible litigation).
   Guidance in the Records Retention and Disposition Schedule says it may be destroyed when the student reaches 29 years of age and has not received services within the last 10 years, if no litigation, claim, audit or other official action involving the records has been initiated. If official action has been initiated, may destroy in the office after completion of action and resolution of issues involved. In reality, most school systems microfilm or archive records within 2-5 years of transfer or graduation so by default, are permanently maintained.
   
   Information includes but is not limited to:
   
   • Nursing Documentation • Medication and procedure logs
   • Physician authorization form, i.e., orders for medication or health care procedures
   • Injury Report Forms
   • Medication Administration Incident Reports
3. Records that are superseded each year: may be destroyed when replaced.
   Once a plan has been replaced with a more current plan, the old one may be destroyed if the plan was never used to provide care. Systems are not required to destroy plans. If you choose to retain plans, the original needs to be stored in the Individual Health Record. Only original forms should be retained. All copies should be shredded.
   
   Information includes but is not limited to the following:
   
   • Individual Health Care Plans
   • Emergency Action Plans
   • Annual Student Health History provided by parents

References

Guidelines for Protecting Confidential Student Health Information. National Task Force on Confidential Student Health Information, American School Health Association, 2000. Kent, Ohio.

Issue Brief: School Health Records. National Association of School Nurses, 2004. Castle Rock, CO.

Legal Issues in School Health Services: A Resource for School Attorneys, School Administrators, School Nurses. Schwab, N. and Gelfman, M., 2001. Sunrise River Press, North Branch, MN.

NC School Health Program Manual. NC Department of Health and Human Services & Public Schools of North Carolina, 2005. Raleigh, NC.

Position Statement of SNANC: School Nursing Records in North Carolina. School Nurse Association of North Carolina, 2006 Raleigh, NC.

Protecting and Disclosing Student Health Information: How to Develop School District Policies and Procedures, American School Health Association, (2005). Kent, Ohio.

Records Retention and Disposition Schedule: Local Education Agencies. NC Dept. of Cultural Resources, Records Services Branch, Feb. 1999.

Created by the Professional Practice & Standards Committee, December 2006 Adopted by: School Nurse Association of North Carolina