Confidentiality, Health Records, and Duty to Report
Cindy Greenberg OSAH Clinical Nurse Consultant
NM Department of Health Office of School & Adolescent Health
[email protected] 505-222-8680
Cynthia Greenberg, RN, BSN, MSN, NCSN
Objectives
1. Describe guidelines for maintaining the confidentiality of student health information.
2. Identify indicators of child abuse/neglect and the duty to report.
What is confidential information?All health information should be considered confidential including verbal, written, and electronic health information.
Confidentiality – Verbal Communication
Verbal Information
Foundational to our health is safety.
Healing and health happen together.
“Sacred information”
Anything a student says to the school health assistant or the nurse is kept confidential.
Few exceptions
Exceptions
Possibility the student is or will:
Harm self
Harm others
Is being harmed or abused
Confidentiality with Written Information – Charting & Records
Written Information Write so we can all read it – only use agreed
upon abbreviations, no texting language Use a pen – black ink preferable
Use standard medical abbreviations
Date and sign each entry note
Report what you observe -avoid judgments and opinions
To correct a mistake:- Draw a line through error and initial. - Do not erase or use white out
“Just the facts, Ma’am”
Legally speaking: If it isn’t documented, it was not done!!!!
Student Health Screenings
Student Health Information:
•Provided by the parent or guardian
• Includes all pertinent health and family history
•Obtained when the student first registers with a school district and is updated each year
Health information is:
Student Health Record/File• Medication order/permission form
• Emergency information
• Original accident report
• Screening, referrals, and follow-up information
• Screening for Special Ed.
• Medical /Health history/ IHPs
• PE or other class restrictions or exemptions
• Health evaluations from outside medical providers &
agencies
• Confidential release forms
• Immunization record or exemptions
• Must be stored safely and securely.
How long are schools required to keep student health records?
[NMAC 1.20.2.101] The student health record includes but is not limited to health history, immunization record, results and recommendations from medical examinations, medical orders, screenings, treatments, parent or guardian referral record, teacher comments, etc.
Must be retained: 10 years after date of last entry or until student attains age 19, whichever is longer.
Child AbuseReporting
Types of Abuse
1. Physical
2. Emotional
3. Sexual
4. Neglect
Child Abuse Reporting
The NM Children’s Code 32A-4-3 states:
Any person who SUSPECTS or HAS KNOWLEDGE
that a child is being abused or neglected is
mandated to report to:
• Local Law Enforcement
• Child Protective Services or
• Tribal Law Enforcement
NM Statewide Central Intake
1-800-797-3260From a cell phone: Text #SAFE (#7233) or Call 1-855-333-SAFE to report suspected child
abuse or neglect
Albuquerque: 841-6100
Required Information:
•Child’s name, age, & date of birth
•Current location
•Parent/guardian name & address
•Name of siblings also at risk
•Name of alleged perpetrator and location
•Description of concerns
Stories and Questions:
REMEMBER:
Do not hesitate to report because of lack of
information—if you suspect abuse, the
information you have is valuable!