School Nursing Records in North Carolina

History
The creation and maintenance of school health records is an integral part of professional school nursing practice. The function of school health records is to communicate student health concerns to school staff/multidisciplinary teams and families that should be addressed to promote effective learning and academic success. Data may be used to gather statistical information and evaluate program outcomes.

Description of Issue
Student health information refers to written, oral and electronic communication regarding physical, mental, and developmental health including records from outside healthcare providers. Policies and procedures that are consistent with Federal Education Rights and Privacy Act (FERPA) must be established to provide guidance in the creation and maintenance of school health records.

Rationale
The school nurse has the expertise to interpret and determine what health information is needed to benefit the student. It is the nurse’s responsibility to create and maintain student health information according to federal and state laws, state and local policies and professional nursing standards. Student health records are subject to Federal Education Rights and Privacy Act (FERPA) law and regulations regardless of the employing agency of the School Nurse.

Conclusion
It is the position of the School Nurse Association of NC (SNANC) that school nurses maintain two types of health records, both of which are stored in the school building where the student is currently enrolled and should be transferred in accordance with student’s enrollment.

1. Student Permanent Health Record
   Every student should have a Student’s Permanent Health Record (PPS-2P) or a similar substitute. The form is provided jointly by the NC Department of Health and Human Services and NC Department of Public Instruction. This document should:
   
   • Be stored in the student’s cumulative folder
   • Contain state required health information
   • Contain pertinent health data impacting academic achievement
   • Be consistent with Student’s Permanent Health Record Guidelines in the Official Forms section of the North Carolina School Health Program Manual
   • Be accessible according to the Local Education Agency Policies/Procedures
2. Individual Health Record
   This record should be initiated when students are seen by the school nurse and may contain non-educationally relevant health information such as:
   
   • Documentation of individual student encounters
   • Health information from outside sources
   • Parent/guardian communication
   This record should be stored in a locked file cabinet easily accessible to the school nurse in the school building where the student is enrolled. The school nurse determines on an individual basis what, to whom, and how much information to share within the school system.

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. North Carolina Department of Cultural Resources, Records Services Branch, Feb. 1999.

Created by: Professional Practice and Standards Committee, May 2006 Adopted by: School Nurse Association of North Carolina, September 15, 2006