School Nurse Orientation Manual. Module 1. Introduction to School Nursing in Washington State

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School Nurse Orientation Manual Module 1 Introduction to School Nursing in Washington State

ESD 105 School Nurse Corps Location: Maggie Perez Student Success Center First Floor 33 S. 2 nd Ave. Yakima, WA 98902 Link to directions to ESD: http://www.esd105.org/domain/33 Staff: SNC Coordinator Amy Norton, RN, BSN, MPA, MPH Phone-509-454-3129 Fax- 509-834-6812 amy.norton@esd105.org Administrative Secretary Erin Balch Phone-454-3128 Fax- 509-834-6812 erin.balch@esd105.org 1

Framework for 21 st Century School Nursing Practice TM STANDARDS OF PRACTICE Community/Public Health STANDARDS OF PRACTICE Care Coordination Students Healthy, Safe, Ready to Learn Family and School Community Quality Improvement Leadership STANDARDS OF PRACTICE National Association of School Nurses, 2015 Better Health. Better Learning. TM 2 Rev. 10/26/15

Framework for 21 st Century School Nursing Practice TM NASN s Framework for 21st Century School Nursing Practice (the Framework) provides structure and focus for the key principles and components of current day, evidence-based school nursing practice. It is aligned with the Whole School, Whole Community, Whole Child model that calls for a collaborative approach to learning and health (ASCD & CDC, 2014). Central to the Framework is student-centered nursing care that occurs within the context of the students family and school community. Surrounding the students, family, and school community are the non-hierarchical, overlapping key principles of Care Coordination, Leadership, Quality Improvement, and Community/Public Health. These principles are surrounded by the fifth principle, Standards of Practice, which is foundational for evidence-based, clinically competent, quality care. School nurses daily use the skills outlined in the practice components of each principle to help students be healthy, safe, and ready to learn. Standards of Practice Care Coordination Leadership Quality Improvement Community/ Public Health Clinical Competence Clinical Guidelines Code of Ethics Critical Thinking Evidence-based Practice NASN Position Statements Nurse Practice Acts Scope and Standards of Practice Case Management Chronic Disease Management Collaborative Communication Direct Care Education Interdisciplinary Teams Motivational Interviewing/ Counseling Nursing Delegation Student Care Plans Student-centered Care Student Selfempowerment Transition Planning Advocacy Change Agents Education Reform Funding and Reimbursement Healthcare Reform Lifelong Learner Models of Practice Technology Policy Development and Implementation Professionalism Systems-level Leadership Continuous Quality Improvement Documentation/Data Collection Evaluation Meaningful Health/ Academic Outcomes Performance Appraisal Research Uniform Data Set Access to Care Cultural Competency Disease Prevention Environmental Health Health Education Health Equity Healthy People 2020 Health Promotion Outreach Population-based Care Risk Reduction Screenings/Referral/ Follow-up Social Determinants of Health Surveillance ASCD & CDC. (2014). Whole school whole community whole child: A collaborative approach to learning and health. Retrieved from http://www.ascd.org/ascd/pdf/siteascd/publications/wholechild/wscc-a-collaborative-approach.pdf National Association of School Nurses, 2015 Better Health. Better Learning. TM 3 Rev. 10/26/15

OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION Health Services Old Capitol Building OLYMPIA WA 98504-7200 (360) 725-6040 TTY (360) 664-3631 ASSESSMENT OF DISTRICT STUDENT HEALTH SERVICES ESD For Official Use Only 2015-2016 PERSON COMPLETING FORM TITLE CONTACT NUMBER Please use 2015-2016 Assessment of District Student Health Services Instructions when completing document SECTION 1 - SCHOOL DISTRICT 1. District Name: 2. District Class: Class I or Class II 3. Number of students: 4. Number of schools: 5. How does your district fund nursing services? Check all that apply. Basic education Grants School Nurse Corps (SNC) Migrant Special education Levies Medicaid Administrative Match Other: Identify SECTION 2 - HEALTH SERVICES 1. How many total licensed nursing hours (including any contract, agency, or SNC hours) per week did the district have this school year? Indicate each category based upon job classification. a. Certificated Registered Nurse hrs/wk b. Classified Registered Nurse hrs/wk c. Other Registered Nurse hrs/wk d. Licensed Practical Nurse hrs/wk How many of the above hours per week of Registered Nurse (RN) service were given by the SNC program this year? hrs/wk No SNC hours 2. Is your district purchasing or contracting any additional hours through the SNC? How many hours per week? hrs/wk No additional hours 3. How many licensed nursing hours per week were 1:1 hours of care this school year? Indicate each category based upon job classification. a. Certificated Registered Nurse hrs/wk b. Classified Registered Nurse hrs/wk c. Other Registered Nurse hrs/wk d. Licensed Practical Nurse hrs/wk 4. How many hours per week did the district have for dedicated health room assistants performing health room activities this year? hrs/wk 5. Indicate the highest level of education for each Registered Nurse (RN). Enter the total number of RNs in each category. a. Associates Degree in Nursing b. Diploma Degree c. Bachelor's Degree in Nursing d. Master's Degree e. Doctorate Degree 6. Enter the number of RNs in each category who have certifications. a. Washington Educational Staff Associate (ESA) Certification b. National Certification for School Nursing (NCSN) 7. Check each service your SNC Nurse Administrator provided for your district this school year: a. Direct Nursing Services d. Technical Assistance/Consultation b. Program Management e. Training/Professional Development c. Resources f. Mentoring/Orientation 23

8. Please indicate the quantity of medications, treatments, and vision and hearing referrals made by your district. Referrals Medications Treatments Vision Hearing 9. Check if your district provides: a. Medication training, delegation, and ongoing RN supervision b. Medical treatment training, delegation, and ongoing RN supervision c. Mandated screening (vision and hearing) programs d. Compliance with immunization laws including exclusion e. Stock epinephrine 10. Does your district have: Yes No a. Stock epinephrine for students with diagnosed anaphylaxis b. Stock epinephrine for students with undiagnosed anaphylaxis 11. How many anaphylactic events occurred in students during school and school sponsored activities? Number of events in student with diagnosed anaphylactic condition Number of events in students without previously diagnosed anaphylactic condition 12. Does your district have a policy allowing the delegation of nasal midazolam? Yes No 13. Please indicate the number of students with orders for each of the following medications and the number of times each of these medications were administered at school. Epinephrine Diastat Midazolam Glucagon # of orders # administered by RN/LPN # administered by PDA # administered by unlicensed staff # student self-administered SECTION 3 - STUDENT HEALTH AND RELATED STAFFING NEEDS 1. Indicate the number of students identified in each of the following levels. Level A: Nursing Dependent Level B: Medically Fragile Level C: Medically Complex Level D: Health Concerns 2. Indicate the number of diagnoses in each category listed below. Known Life Threatening Number of Chronic Health Conditions Cases per Law RCW Care Plans (Standardized Codes) 28A.210.320 ADHD / ADD Anaphylaxis (severe allergy) Asthma Cardio-vascular Developmental Conditions (DD; Asperger's; Autism; Downs) Diabetes, Insulin Dependent (IDDM) Diabetes, Non-Insulin Dependent (NIDDM), Obesity Hematological Mental / Behavioral Health Neurologic Oncological Seizures Traumatic Brain Injury Vision/hearing deficits (not corrective lenses) Number of conditions not noted above (do not list) Total 24

3. Please calculate how many RN hours per week would be needed using the OSPI/DOH Staff Model for Delivery of School Health Services for the entire school district. Do not include any LPN hours in this chart. Worksheet available. a. Enter the total number of sites (or groups of buildings in close proximity in the district). A site may include multiple schools or school buildings with a relatively small number of students in close proximity (2-3 minute walk). Please remember to use your nursing judgment. b. Total number of students in the district. (from Section 1.3) c. Total number of level Bs for the district. B = Medically Fragile (from Section 3) d. Total number of level Cs for the district. C = Medically Complex (from Section 3) e. Number of RN hours required based upon a 1:1500 nurse to student ratio. (b x 40/1500) f. Enter the total number of nursing hours required based upon the number of level Bs and Cs. g. Enter the total number of RN hours needed for the district based upon e and f above and your nursing judgment considering the answers in columns E (1:1500 ratio) and F (number of Level B and C students). Often times the staffing needed for severity levels adequately meets the need for the 1:1500 ratio as well, however, this is not always the case. Your nursing judgment is required. h. Total number of RN hours (excluding 1:1 hours) currently assigned. (Section 2.1 a, b and c minus Section 2.3 a, b and c) i. Difference of RN hour of need based upon OSPI/DOH staff model (g- h). SECTION 4 - DATA 1. Data Collection a. Are you currently using a computer program(s) designed to collect health data? b. Name of program(s): Aspen E-School Plus Excel Power School School Master Skyward Tyler SIS Synergy WA-IIS Name of other program used to collect health data: c. Check the components of the student information system program you are currently using: Correspondence Daily Log - Health Room Visits Immunization Individual Health Care Plans Student Information Student Reports Emergency Care Plans Health Card Medication Records Screenings d. Are you using Washington State School Nurse Data Codes? e. Are you collecting student health room visit disposition information in any of your schools? Yes Yes No No If yes, how many student visits, seen by the RN, were: Returned to school activities Released to EMS Released from school If yes, how many student visits, seen by other staff (not RN), were: Returned to school activities Released to EMS Released from school 2. Are you currently using student health data to identify the impact of school nurse interventions on student health and educational outcomes (for example: improved attendance, test scores, grades, graduation rates)? Yes No If yes, please briefly describe: 25

SECTION 5 - TO BE REVIEWED WITH SCHOOL ADMINISTRATOR Name of Administrator 1. School Nurse Impact, the school nurse has contributed to school health services in the following areas: a. Student assessment, health problem identification, referral and follow-up b. Consultation to school personnel on educational impact of health concerns c. Health counseling and crisis intervention d. Direct nursing service and emergency service as needed e. Health education to staff f. Health education to students g. Development of individualized educational plans (IEPs) h. Development of Section 504 accommodation plans i. Identification of school safety and environmental health needs j Improved attendance for students with health concerns k. Increased protection from liability l. Increased compliance with school and health regulations m. Computerized health data installation, collection, or training Yes No 2. Provide at least one anecdotal story about how your nursing assessment and interventions have positively impacted a student or staff member? (Use additional paper if necessary) 3. Unmet Needs Rank your district's unmet needs for health services. Mark an X in the appropriate box to indicate high need, medium need, low need, or no need: High Med Low No a. Direct nursing service time. b. Medication policy, training, delegation, and ongoing supervision. c. Care plan development, training, delegation and ongoing supervision. d. Mandated screening programs. e. Compliance with immunization regulations. f. Student health services management software program. g. Health education classes and/or presentations. h. Individual health education/counseling. k. Behavioral health assessment and intervention. j. Policy/procedure development. i. Communicable disease control. l. Other (specify): SECTION 6 - OTHER INFORMATION Please attach any additional data or anecdotal information you are willing to share. Return to ESD SNC Nurse Administrator. 26

2015-16 District Assessment Instrutions Thank you for taking time to complete this district assessment. The data is critical for the Office of Superintendent of Public Instruction (OSPI), School Districts and Educational Service Districts (ESDs) to manage: Health services in schools, The incidence of complex health issues in schools, Related trends and needs(student health and staffing), If you have any questions, please contact your regional School Nurse Corps (SNC) Nurse Administrator. Contact information is available at: http://www.k12.wa.us/healthservices/schoolnurse.aspx. You may complete the district assessment on paper or in Excel and send to the ESD SNC Nurse Administrator in your area. (The Excel version is available from the ESD SNC Nurse Administrator). Throughout the assessment, please answer all questions as completely and accurately as possible, based on your current knowledge and available information. Except for hours per week, round all numbers to the nearest whole number. This information is not a direct reflection of your practice, but rather a reflection of the services available given financial, physical, and time constraints. Data provides a snapshot of health services and related needs at the time you complete the assessment. SECTION 1 SCHOOL DISTRICT 1. Enter the district name. 2. Enter the official district Class I or II (check with your district office if you are unclear). 3. Enter the total number of students in the district. This is the head count (not FTE) for all students under the care of the district during school or school sponsored activities. Include pre-schools, home-school students, and alternative students. 4. Enter the number of schools within your district (not necessarily equal to the buildings). Some buildings may house more than one school. If you are not sure, check with your district office or go to http://data.k12.wa.us/publicdwp/web/washingtonweb/snapshots/overview.aspx and click on the plus next to your district s name to see the schools OSPI lists for your district OR look up in Washington Education Directory 2015-2016 book. 5. Check each box that helps to fund nursing services in your district. 27

SECTION 2 HEALTH SERVICES 1. Enter, in each category (a through d), the number of licensed nursing hours per week the district provides based upon employee job classification. (may use decimals) 1c. Other Registered Nurse (RN) may include those employed by hospitals, agencies, local health jurisdictions, independent contractors, etc. Enter the number of RN hours funded by the School Nurse Corps (SNC). (may use decimals) If no SNC funding for school nurse hours, check no SNC hours. 2. If your district purchased or contracted additional hours through the SNC, indicate the number of hours per week. (may use decimals) If not, check no additional hours. 3. Enter, in each category (a through d), the number of licensed nursing hours per week the district provided for 1:1 care based upon employee job classification. (may use decimals) 3c. Other Registered Nurse may include those employed by hospitals, agencies, local health jurisdictions, independent contractors, etc. 4. Enter the number of hours per week the district provided funding dedicated specifically for health room assistants performing health room activities. (This does not include the secretary who does health room activities as part of his/her regular secretarial job). (may use decimals) 5. Enter the number of RNs in each category (a through e) according to the highest level of education completed. 6. Enter the number of RNs in each category (a and b) that hold a certification. 7. Check the box(es) of any of the following services your district received from the ESD SNC Nurse Administrator. a. Direct Nursing Services: School nurse services performed on site, e.g. developing Individual Healthcare Plans (IHPs) or Emergency Care Plans (ECPs), coordinating and/or providing health screenings, overseeing immunization records, delegation and supervision of unlicensed staff in administration of medications or providing medical procedures, etc. b. Program Management: Oversight of activities related to SNC program goals and objectives. c. Resources: Examples include use of the SNC resource library; requesting or receiving materials, supplies, sample forms, etc. d. Technical Assistance and Consultation: This may be phone/email consultation, on site consultation, training, or technical assistance. 28

e. Training and Professional Development: Provided or contributed to training or continuing education opportunities through various regional meetings or in-services such as SNC, the School Nurse Organization of Washington, K 20, etc. f. Mentoring and Orientation: Provided mentoring, guidance, and/or support for all nurses and orientation for nurses new to school nursing. 8. Enter the total number for each category noted in the table: Count all medications ordered: daily, as needed (PRN) and emergency medications. Count all medication, not just scheduled. Count all medical treatments ordered, not times per day treatment is provided. Examples of medical treatment may include tube feedings, catheterizations, oral suctioning, glucose monitoring, etc. Indicate the number of students referred for vision and hearing. 9. Check each box to indicate if your district provides the services described. 10. Check yes or no to the questions regarding stock epinephrine 11. Enter the total number of events in school this school year where students who did not have known anaphylactic condition had an anaphylactic reaction. In school means any time student is participating in a school sponsored activity. 12. Check yes or no to the question regarding delegation of nasal midazolam. 13. Enter the counts of: The number of medication orders for the following: o o o o Epinephrine for anaphylaxis, severe allergy or asthma Rectal Diastat for seizure Intra-Nasal Midazolam for seizure Glucagon for severe low blood sugar. The number of times medication given by RN or LPN for the following: o o o o Epinephrine for anaphylaxis, severe allergy or asthma Rectal Diastat for seizure Intra-Nasal Midazolam for seizure Glucagon for severe low blood sugar. The number of times medication given by a PDA for the following: o o Intra-Nasal Midazolam for seizure Glucagon for severe low blood sugar. The number of times medication given by unlicensed staff for the following: 29

o Epinephrine for anaphylaxis, severe allergy or asthma o Intra-Nasal Midazolam for seizure The number of times a student self-administered epinephrine SECTION 3 STUDENT DATA 1. Indicate the number of students in each severity level as described in the Staff Model. Use the Staff Model for the Delivery of School Health Services, (http://www.k12.wa.us/healthservices/pubdocs/schhealth.pdf) to determine the number of students in each severity level. A brief explanation of the staffing model: Level A (Nursing Dependent) students require 24 hours a day, frequently oneto-one skilled nursing care. Level B (Medically Fragile) students require a full-time nurse in the building. Level C (Medically Complex) students require an RN one day a week and access to a nurse the rest of the week. Level D (Health Concerns) students require their health care needs assessed at least once a school year by a RN. Required monitoring varying from every two weeks to annually. Co-morbidity or single student with multiple concerns: Placement of a student at a particular level requires nursing judgment considering all conditions and any other life situations which may increase or decrease the student s need for nursing availability. A student s severity level may change during the year; therefore, record the severity level of a student at the time of the district assessment. Students should be listed only one time in one category (A, B, C, or D) at their highest severity level. For example: For a student with three diagnoses: diabetes, depression, and migraine headaches, determine and record one severity level considering the student s multiple diagnoses and other life situations. Based upon previously reported data, the greatest discrepancy is determining whether to place a student in level C or D. In order to provide consistency in our data we request the following: If a student requires medication and/or a medical treatment (including PRN s) at school and a nursing care plan, the student is most often a level C. All students with life-threatening health conditions should have a nursing care plan and medication/treatment orders in place. There may be exceptions to this guidance based upon clinical nursing judgment. Some students may need more or less RN 30

time resulting in you (the nurse) placing them in level B or D. 2. Indicate the number of Health Conditions, not the number of students with health conditions in each category listed in the table. Total each column. For example: If you have one student with diabetes, depression, and migraine headaches, count and record each of the three conditions. If you use Washington State School Nurse Data Sets, the table below describes which codes are contained in the conditions listed. a. ADHD / ADD NB b. Anaphylaxis (Severe Allergy) EG c. Asthma RA; RB; RC; RD; RE d. Cardio-vascular CA; CB; CC; CD; CE; CF; CG e. Developmental Conditions (DD; Asperger s, Autism; Downs) AH; NA; NC; NF; NL f. Diabetes Insulin Dependent EK g. Diabetes Non-Insulin; Obesity EL; ES h. Hematological BA; BB; BC; BD i. Mental / Behavioral Health PA; PB; PC; PD; PE; PD; PF; PG; PH; PI; PJ j. Neurologic ND; NE; NG; NH; NI; NJ; NK; NM; NN; NO; NQ; NR; NS; NT k. Oncological TA; TB; TC; TD; TE; TF; TG; TH; TI l. Seizures NP m. Traumatic Brain Injury NU n. Vision/Hearing Deficits (not corrective lenses) YA; YB; YD o. Other conditions not reported All other conditions/codes Life threatening condition-a health condition that will put the child in danger of death during the school day if a medication or treatment order and a nursing plan are not in place. RCW 28A.210.320(4) Care Plans: Count the number of care plans related to the condition(s) as listed. A student with a condition may have an emergency care plan, an individualized healthcare 31

plan and perhaps a 504 or individualized education plan. Since the plans are for the same student and that condition, count them as one (1) plan. This follows that all these plans combined constitute the plan of care for the student. Some students have multiple conditions in one care plan. An example would be a student with severe allergies and asthma. Because the plan counts are related to the condition and not the student, you would count one plan for each condition. 3. The instructions below will help you complete all fields. a. Enter the total number of sites (groups of buildings within close proximity) within your district. A site may include multiple schools or school buildings with a relatively small number of students in close proximity (2-3 minute walk). Please remember to use your nursing judgment. b. Use the same number from Section 1.3. c. Use the same number from Section 3.1 Level B: Medically Fragile. d. Use the same number from Section 3.1 Level C Medically Complex. e. Take the total number of students and multiply by 40, then divided by 1500 and enter the result. f. For each site with Level B students count 40 hours per week. For each site with Level C students that does not have Level B students, count 8 hours per week. Do not subtract current hours in building. Enter the total hours for all buildings. g. Determining RN hours needed requires your nursing judgment. Consider 1:1500 ratio, severity levels as well as other individual student, school population, and building needs and enter that number. Be prepared to share how you determined the number of hours needed when you discuss this with district administration. h. Enter the total number of RN hours (excluding 1:1 time) currently assigned to your district. Take Section 2.1 a, b, and c and subtract Section 2.3 a, b, and c, for the total number of RN hours. i. Enter the difference between h and g by subtracting h from g. **OPTIONAL INSTRUCTIONS IF COMPLETING THE STAFFING WORKSHEET** Only complete columns A, F, and G. When the results are sent to the ESD, the SNC Administrator forms will calculate the shaded columns B, C, D, E, H, and I. A. Enter the total number of sites (groups of buildings within close proximity) within your district. A site may include multiple schools or school buildings with a 32

relatively small number of students in close proximity (2-3 minute walk). Please remember to use your nursing judgment. F. For each site with Level B students count 40 hours per week. For each site with Level C students that does not have Level B students, count 8 hours per week. Do not subtract current hours in building. Enter the total hours for all buildings. G. Determining RN hours needed requires your nursing judgment. Consider 1:1500 ratio, severity levels as well as other individual student, school population, and building needs and enter that number. Be prepared to share how you determined the number of hours needed when you discuss this with district administration. The instructions below will help you manually complete ALL fields if you are interested. A. Enter the total number of sites (groups of buildings within close proximity) within your district. A site may include multiple schools or school buildings with a relatively small number of students in close proximity (2-3 minute walk). Please remember to use your nursing judgment. B. Use the same number from Section 1.3 C. Use the same number from Section 3.1 Level B: Medically Fragile D. Use the same number from Section 3.1 Level C: Medically Complex E. Take the total number of students and multiply by 40, then divide by 1500 and enter the results F. For each site with Level B students count 40 hours per week. For each site with Level C students that does not have Level B student, count 8 hours per week. Do not subtract current hours in building. Enter the total hours for all buildings. G. Determining RN hours needed requires nursing judgment. Consider 1:1500 ratio, severity levels as well as other individual student, school population, and building needs and enter that number. Be prepared to share how you determined the number of hours needed when you discuss this with district administration. H. Enter the total number of RN hours (excluding 1:1 time) currently assigned to your district. Take section 2 number 1 and subtract section 2 number 3 for the total number of RN hours. I. Enter the difference between column H and column G by subtracting H from G. SECTION 4 DATA 1. Data Collection a. Check yes or no to the question regarding the use of a computer program. 33

b. Indicate the program your district is using and check all that apply. c. Check the components of the student information system program you are currently using d. Check yes or no if using WA State School Nurse Data Sets. Ask your School Nurse Corps Nurse Administrator for information about these codes. e. Check yes or no if you collect health room disposition data. If Yes, indicate number of student visits seen by RN and report disposition. If Yes, indicate number of student visits seen by other staff (not RN) and report disposition. 2. Are you currently using student health data to identify the impact of school nurse interventions on school health and educational outcomes (for example: improved attendance, test scores, grades, and graduation rates)? If yes, please describe. SECTION 5 TO BE COMPETED BY THE SCHOOL NURSE AND REVIEWED WITH SCHOOL ADMINISTRATOR 1. School Nurse Impact: District administration and each building administrator should have understanding of and input into this section. Schedule an appointment with your district superintendent or appropriate administrator to review and discuss your findings. Be ready with specific examples without compromising confidentiality. 2. Provide at least one anecdotal story about how your nursing assessment and interventions have positively impacted a student or a staff member. Your success stories support quantitative data. Your stories paint the picture for others illustrating what nurses do in schools and how they affect children, families, and staff. 3. Unmet Needs: To be completed and encourage to discuss with school and/or district administrator. SECTION 6 OTHER INFORMATION Please attach additional comments on any aspect of the assessment. Return your completed assessment to your regional ESD SNC Nurse Administrator. Thank you! 34

"Chronic Health Condition" Data Codes Coding Explanation: Only two characters are currently proposed for coding of chronic health condition data. The first character reflects the ICD-9 disease / body system category (e.g., nervous, respiratory, musculoskeletal, etc.) of the specific condition. The second character reflects a unique identifier for each condition within each ICD-9 category, and was randomly assigned. The combined first and second characters comprise a code, which defines a specific chronic health condition. A third character could be added for greater specificity of conditions, if such need were defined later. 1st Character (ICD-9 Disease / Body System Category) Congenital Conditions A Hematology (Blood) B Cardiovascular C Endocrine, Allergy, Immune System, MetabolicE Gastro-Intestinal, Dental, and Oral Conditions G Musculoskeletal and Connective Tissue M Nervous System N Other Conditions O Mental or Behavioral Health Conditions (PsychP Respiratory R Skin and Subcutaneous Tissue S Neoplasms (Tumors) T Renal and Genitourinary U Eye and Ear Y Other Conditions/Interventions Z Character Chronic Health Conditions 1 2 3 Long Description (30 char.) Short Description (15 char. Narrative A A Charcot-Marie Tooth Syndrome Charcot-Marie A B CHARGE Syndrome CHARGE Syndrome A C Cleft Lip Cleft Lip A D Cleft Lip and Palate Cleft Lp/Palate A E Cleft Palate Cleft Palate A F Congenital Adrenal Hyperplasia Adrnl Hyprplsia A G Congenital Cndtn - Othr Congnital-Othr A H Down's Syndrome Down's Syndrome A I Ehlers-Danlos Syndrome Ehlers-Danlos A J Fetal Alcohol Syndrome Fetal Alcohol A K Prader - Willi Syndrome Prader - Willi A L Rett's Syndrome Rett's Syndrome A M Velocardiofacial Velocardiofacl B A Anemia Anemia B B Hemophilia Hemophilia B C Sickle Cell Anemia Sickle Cell B D Blood Cndtn - Othr Blood - Other C A Cardiac Disorder Cardiac Disordr C B Cardiac Dysrhythmia Card.Dysrythmia C C Heart Birth Defect Congenital Hrt C D Heart Murmur Heart Murmur C E Hypertension Hypertension C F Raynaud's Disease Raynaud's 35

C G Cardiovascular Cndtn - Othr CardVas - Other E A Adrenal Disorder Adrenal Disordr E B Allergy - Othr Allergy - Other E C Allergy - Environmental Allrgy Environ E D Allergy - Food Allergy - Food E E Allergy - Insect Allrgy-Insect E F Allergy - Latex Allergy - Latex E G Anaphylactic Cndtn Anaphylactic E H Anorexia Nervosa Anorexia Nrvosa E I Bulimia Bulemia E J Cystic Fibrosis Cystic Fibross E K Diabetes Type I Diabetes Type I E L Diabetes Type II Diabetes Type 2 E M Drug Allergy Drug Allergy E N Eating Disorder - Othr Eat Dsrdr-Othr E O Endocrine/Mtblc Cndtn - Othr Endo-Metab-Othr E P HIV/AIDS HIV/AIDS E Q Immune Cmprmsd Cndtn - Othr Imun Comp-Othr E R Nutritional Disorder - Othr Nutrition-Othr E S Obesity Obesity E T Phenylketonuria Phenylketonuria E U Thyroid Disorder Thyroid Disordr G A Celiac Disease Celiac Disease G B Chronic Hepatitis Chron Hepatitis G C Dental Caries Dental Caries G D Dental Cndtn - Othr Dental-Other G E Dysphagia Dysphagia G F Encopresis Encopresis G G Food Intolerance Food Intoleranc G H Gastroesophageal Reflux GERD G I Gastro-intstnl Cndtn - Othr GI - Other G J Inflammatory Bowel Disease Inflamm Bowel Includes Crohn's and G K Irritable Bowel Syndrome Irritable Bowel G L Lactose Intolerance Lactose Intoler G M Liver Disease Liver Disease G N Oral Cndtn - Othr Oral - Other G O Chronic Consitpation ChronConstipatn M A Club Feet Club Feet M B Connective Tssu Cndtn - Othr Cnnective Other M C Juvenile Rheumatoid Arthritis Juvenile RA M D Muscular Dystrophy Muscular Dys M E Musculoskeletal Cndtn - Othr Musc-skel-Othr M F Osgood-Schlatter Disease Osgood-Schlattr M G Osteogenesis Imperfecta Osteogensis Imp M H Scoliosis Scoliosis M I Spinal Curvature Cndtn - Othr Spin Crv-Other M J Systemic Lupus Erthyematosus SLupusE N A Asperger's Syndrome Asperger's N B ADHD/ADD ADHD/ADD N C Autism Autism N D Cntrl Nrvs Stm Cndtn - Othr CNS/Neuro-Othr N E Cerebral Palsy Cerebral Palsy N F Developmental Delay Develop-Delay N G Encephalitis Encephalitis N H Headache, Migraines Headache/Migrns 36

N I Headaches, Recurring Headaches/Recur N J Hydrocephalus Hydrocephalus N K Hypersensitivity Hypersensitiv N L Intellectual Disability IntellectDisability Change term, same definition, see https://www.federalregister.gov/arti cles/2013/08/01/2013-18552/change-in-terminologymental-retardation-to-intellectualdisability N M Neurofibromatosis Neurofibromatosis N N Paralysis Paralysis N O Prphrl Nrvs Stm Cndtn - Othr Peri Nrv-Other N P Seizure Disorder Seizure Dsrdr N Q Sensory Cndtn - Othr Sensory-Other N R Sensory Integration Disorder Sensory Intgrat N S Spina Bifida Spina Bifida N T Spinal Cord Injury Spinal Cord Inj N U Traumatic Brain Injury Trauma Brain I O A Declines to Report Declines Report Guardian declines to O B Life Threatening Cndtn Life Threatning O C No Cndtn Reported by Guardian NoKnwn Chronic O D Organ Transplant Organ Trans O E Severity Code A Severity Code A O F Severity Code B Severity Code B O G Severity Code C Severity Code C O H Severity Code D Severity Code D O I Speech Impairment Speech Impair Includes all forms of O J Chronic Nosebleeds Chronic Nosebld History of multiple P A Anxiety Anxiety P B Bipolar Disorder Bipolar Disordr P C Depression Depression P D Obsessive Compulsive Disorder Obses Compuls D P E Oppositional Defiant Disorder Oppos Defiant D P F Post Traumatic Stress Syndrome PTSD P G Schizophrenia Schizophrenia P H Sleep Disorder Sleep Disorder P I Tourette's Syndrome Tourette's Synd P J Mntl/Bhvrl Hlth Cndtn - Othr Mntl/BehavOthr R A Asthma - Exercise Induced Asthma-Exercise R B Asthma - Mild Asthma - Mild R C Asthma - Moderate Asthma - Mod R D Asthma - Severe Asthma - Severe R E Reactive Airway Disease Reactive Airway R F Respiratory Cndtn - Othr Resp - Other S A Acne (Chronic) Acne (Chronic) S B Dermatitis Dermatitis Define as inflamed skin, include contact, psoriasis, eczema, etc- Describe in Notes S C Erythema Multiforme Erythema Multif S D Lichen Lichen S E Lupus Lupus S F Psoriasis Psoriasis 37

S G Rosacea Rosacea S H Skin Cndtns - Othr Skin - Other T A Neoplasm - Blood/crcltry Nplsm-Bld/Circ Includes Leukemia T B Neoplasm - Bone Neoplasm-Bone T C Neoplasm - Central Nrvs Sstm Neoplasm - CNS T D Neoplasm - EEN or T Neoplasm - EENT T E Neoplasm - Gastrointestinal Neoplasm - GI T F Neoplasm - Genitourinary Neoplasm - GU T G Renal Neoplasm Renal Neoplasm T H Skin Neoplasm Skin Neoplasm T I Neoplasm - Othr Neoplasm-Other U A Chronic Renal Failure ChroncRenalFail U B Chronic Urinary Tract Infctn Chronic UrinaTI U C Dysmenorrhea Dysmenorrhea U D Genito-Urinary Cndtn - Othr GU-Other U E Incontinence Incontinence U F Neurogenic Bladder NeurogenicBlddr U G One Kidney One Kidney U H Renal Cndtn - Othr Renal - Other Y A Chronic Otitis Media ChrncOtitisMedi Y B Hearing Impaired Hearing Impaire Y C Ear Cndtn - Othr Ear Cndtn-Othr Y D Visually Impaired Visually Impair severe visual limmitation Y E Eye Cndtn - Othr Eye - Other Y F Uses corrective lenses CorLenses has glasses or contacts 38

U.S. Department of Health and Human Services U.S. Department of Education Joint Guidance on the Application of the Family Educational Rights and Privacy Act (FERPA) And the Health Insurance Portability and Accountability Act of 1996 (HIPAA) To Student Health Records November 2008 112

Contents I. Introduction... 1 II. Overview of FERPA.. 1 III. Overview of HIPAA... 2 IV. Where FERPA and HIPAA May Intersect.. 3 V. Frequently Asked Questions and Answers.. 3 1. Does the HIPAA Privacy Rule apply to an elementary or secondary school? 2. How does FERPA apply to health records on students maintained by elementary or secondary schools? 3. Does FERPA or HIPAA apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school? 4. Are there circumstances in which the HIPAA Privacy Rule might apply to an elementary or secondary school? 5. Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a troubled teen to the parents of the teen? 6. Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a student to a school nurse or physician? 7. Does FERPA or HIPAA apply to records on students at health clinics run by postsecondary institutions? 8. Under FERPA, may an eligible student inspect and review his or her treatment records? 9. Under FERPA, may an eligible student s treatment records be shared with parties other than treating professionals? 10. Under what circumstances does FERPA permit an eligible student s treatment records to be disclosed to a third-party health care provider for treatment? 11. Are all student records maintained by a health clinic run by a postsecondary institution considered treatment records under FERPA? 12. Does FERPA or HIPAA apply to records on students who are patients at a university hospital? 13. Where the HIPAA Privacy Rule applies, does it permit a health care provider to disclose protected health information (PHI) about a patient to law enforcement, family members, or others if the provider believes the patient presents a serious danger to self or others? 14. Does FERPA permit a postsecondary institution to disclose a student s treatment records or education records to law enforcement, the student s parents, or others if the institution believes the student presents a serious danger to self or others? 15. Are the health records of an individual who is both a student and an employee of a university at which the person receives health care subject to the privacy provisions of FERPA or those of HIPAA? 16. Can a postsecondary institution be a hybrid entity under the HIPAA Privacy Rule? VI. Conclusion 11 113

I. Introduction The purpose of this guidance is to explain the relationship between the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule, and to address apparent confusion on the part of school administrators, health care professionals, and others as to how these two laws apply to records maintained on students. It also addresses certain disclosures that are allowed without consent or authorization under both laws, especially those related to health and safety emergency situations. While this guidance seeks to answer many questions that school officials and others have had about the intersection of these federal laws, ongoing discussions may cause more issues to emerge. Contact information for submitting additional questions or suggestions for purposes of informing future guidance is provided at the end of this document. The Departments of Education and Health and Human Services are committed to a continuing dialogue with school officials and other professionals on these important matters affecting the safety and security of our nation s schools. II. Overview of FERPA FERPA is a Federal law that protects the privacy of students education records. (See 20 U.S.C. 1232g; 34 CFR Part 99). FERPA applies to educational agencies and institutions that receive funds under any program administered by the U.S. Department of Education. This includes virtually all public schools and school districts and most private and public postsecondary institutions, including medical and other professional schools. If an educational agency or institution receives funds under one or more of these programs, FERPA applies to the recipient as a whole, including each of its components, such as a department within a university. See 34 CFR 99.1(d). Private and religious schools at the elementary and secondary level generally do not receive funds from the Department of Education and are, therefore, not subject to FERPA. Note that a private school is not made subject to FERPA just because its students and teachers receive services from a local school district or State educational agency that receives funds from the Department. The school itself must receive funds from a program administered by the Department to be subject to FERPA. For example, if a school district places a student with a disability in a private school that is acting on behalf of the school district with regard to providing services to that student, the records of that student are subject to FERPA, but not the records of the other students in the private school. In such cases, the school district remains responsible for complying with FERPA with respect to the education records of the student placed at the private school. An educational agency or institution subject to FERPA may not have a policy or practice of disclosing the education records of students, or personally identifiable information from education records, without a parent or eligible student s written consent. See 34 CFR 99.30. FERPA contains several exceptions to this general consent rule. See 34 CFR 99.31. An eligible student is a student who is at least 18 years of age or who attends a postsecondary institution at any age. See 34 CFR 99.3 and 99.5(a). Under FERPA, parents and eligible students have the right to inspect and review the student s education records and to seek to have them amended in certain circumstances. See 34 CFR 99.10 99.12 and 99.20 99.22. The term education records is broadly defined to mean those records that are: (1) directly related to a student, and (2) maintained by an educational agency or institution or by a party acting for the 1 114

agency or institution. See 34 CFR 99.3. At the elementary or secondary level, a student s health records, including immunization records, maintained by an educational agency or institution subject to FERPA, as well as records maintained by a school nurse, are education records subject to FERPA. In addition, records that schools maintain on special education students, including records on services provided to students under the Individuals with Disabilities Education Act (IDEA), are education records under FERPA. This is because these records are (1) directly related to a student, (2) maintained by the school or a party acting for the school, and (3) not excluded from the definition of education records. At postsecondary institutions, medical and psychological treatment records of eligible students are excluded from the definition of education records if they are made, maintained, and used only in connection with treatment of the student and disclosed only to individuals providing the treatment. See 34 CFR 99.3 Education records. These records are commonly called treatment records. An eligible student s treatment records may be disclosed for purposes other than the student s treatment, provided the records are disclosed under one of the exceptions to written consent under 34 CFR 99.31(a) or with the student s written consent under 34 CFR 99.30. If a school discloses an eligible student s treatment records for purposes other than treatment, the records are no longer excluded from the definition of education records and are subject to all other FERPA requirements. The FERPA regulations and other helpful information can be found at: http://www.ed.gov/policy/gen/guid/fpco/index.html. III. Overview of HIPAA Congress enacted HIPAA in 1996 to, among other things, improve the efficiency and effectiveness of the health care system through the establishment of national standards and requirements for electronic health care transactions and to protect the privacy and security of individually identifiable health information. Collectively, these are known as HIPAA s Administrative Simplification provisions, and the U.S. Department of Health and Human Services has issued a suite of rules, including a privacy rule, to implement these provisions. Entities subject to the HIPAA Administrative Simplification Rules (see 45 CFR Parts 160, 162, and 164), known as covered entities, are health plans, health care clearinghouses, and health care providers that transmit health information in electronic form in connection with covered transactions. See 45 CFR 160.103. Health care providers include institutional providers of health or medical services, such as hospitals, as well as non-institutional providers, such as physicians, dentists, and other practitioners, along with any other person or organization that furnishes, bills, or is paid for health care in the normal course of business. Covered transactions are those for which the U.S. Department of Health and Human Services has adopted a standard, such as health care claims submitted to a health plan. See 45 CFR 160.103 (definitions of health care provider and transaction ) and 45 CFR Part 162, Subparts K R. The HIPAA Privacy Rule requires covered entities to protect individuals health records and other identifiable health information by requiring appropriate safeguards to protect privacy, and setting limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections. 2 115

IV. Where FERPA and HIPAA May Intersect When a school provides health care to students in the normal course of business, such as through its health clinic, it is also a health care provider as defined by HIPAA. If a school also conducts any covered transactions electronically in connection with that health care, it is then a covered entity under HIPAA. As a covered entity, the school must comply with the HIPAA Administrative Simplification Rules for Transactions and Code Sets and Identifiers with respect to its transactions. However, many schools, even those that are HIPAA covered entities, are not required to comply with the HIPAA Privacy Rule because the only health records maintained by the school are education records or treatment records of eligible students under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule. See the exception at paragraph (2)(i) and (2)(ii) to what is considered protected health information (PHI) at 45 CFR 160.103. In addition, the exception for records covered by FERPA applies both to the HIPAA Privacy Rule, as well as to the HIPAA Security Rule, because the Security Rule applies to a subset of information covered by the Privacy Rule (i.e., electronic PHI). Information on the HIPAA Privacy Rule is available at: http://www.hhs.gov/ocr/hipaa/. Information on the other HIPAA Administrative Simplification Rules is available at: http://www.cms.hhs.gov/hipaageninfo/. V. Frequently Asked Questions and Answers 1. Does the HIPAA Privacy Rule apply to an elementary or secondary school? Generally, no. In most cases, the HIPAA Privacy Rule does not apply to an elementary or secondary school because the school either: (1) is not a HIPAA covered entity or (2) is a HIPAA covered entity but maintains health information only on students in records that are by definition education records under FERPA and, therefore, is not subject to the HIPAA Privacy Rule. The school is not a HIPAA covered entity. The HIPAA Privacy Rule only applies to health plans, health care clearinghouses, and those health care providers that transmit health information electronically in connection with certain administrative and financial transactions ( covered transactions ). See 45 CFR 160.102. Covered transactions are those for which the U.S. Department of Health and Human Services has adopted a standard, such as health care claims submitted to a health plan. See the definition of transaction at 45 CFR 160.103 and 45 CFR Part 162, Subparts K R. Thus, even though a school employs school nurses, physicians, psychologists, or other health care providers, the school is not generally a HIPAA covered entity because the providers do not engage in any of the covered transactions, such as billing a health plan electronically for their services. It is expected that most elementary and secondary schools fall into this category. The school is a HIPAA covered entity but does not have protected health information. Where a school does employ a health care provider that conducts one or more covered transactions electronically, such as electronically transmitting health care claims to a health plan for payment, the school is a HIPAA covered entity and must comply with the HIPAA Transactions and Code Sets and Identifier Rules with respect to such transactions. However, even in this case, many schools would not be required to comply with the HIPAA Privacy Rule because the school maintains health information only in student health records that are education records under FERPA and, thus, not protected health information under 3 116

HIPAA. Because student health information in education records is protected by FERPA, the HIPAA Privacy Rule excludes such information from its coverage. See the exception at paragraph (2)(i) to the definition of protected health information in the HIPAA Privacy Rule at 45 CFR 160.103. For example, if a public high school employs a health care provider that bills Medicaid electronically for services provided to a student under the IDEA, the school is a HIPAA covered entity and would be subject to the HIPAA requirements concerning transactions. However, if the school s provider maintains health information only in what are education records under FERPA, the school is not required to comply with the HIPAA Privacy Rule. Rather, the school would have to comply with FERPA s privacy requirements with respect to its education records, including the requirement to obtain parental consent (34 CFR 99.30) in order to disclose to Medicaid billing information about a service provided to a student. 2. How does FERPA apply to health records on students maintained by elementary or secondary schools? At the elementary or secondary school level, students immunization and other health records that are maintained by a school district or individual school, including a school-operated health clinic, that receives funds under any program administered by the U.S. Department of Education are education records subject to FERPA, including health and medical records maintained by a school nurse who is employed by or under contract with a school or school district. Some schools may receive a grant from a foundation or government agency to hire a nurse. Notwithstanding the source of the funding, if the nurse is hired as a school official (or contractor), the records maintained by the nurse or clinic are education records subject to FERPA. Parents have a right under FERPA to inspect and review these health and medical records because they are education records under FERPA. See 34 CFR 99.10 99.12. In addition, these records may not be shared with third parties without written parental consent unless the disclosure meets one of the exceptions to FERPA s general consent requirement. For instance, one of these exceptions allows schools to disclose a student s health and medical information and other education records to teachers and other school officials, without written consent, if these school officials have legitimate educational interests in accordance with school policy. See 34 CFR 99.31(a)(1). Another exception permits the disclosure of education records, without consent, to appropriate parties in connection with an emergency, if knowledge of the information is necessary to protect the health or safety of the student or other individuals. See 34 CFR 99.31(a)(10) and 99.36. 3. Does FERPA or HIPAA apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school? If a person or entity acting on behalf of a school subject to FERPA, such as a school nurse that provides services to students under contract with or otherwise under the direct control of the school, maintains student health records, these records are education records under FERPA, just as they would be if the school maintained the records directly. This is the case regardless of whether the health care is provided to students on school grounds or off-site. As education records, the information is protected under FERPA and not HIPAA. 4 117

Some outside parties provide services directly to students and are not employed by, under contract to, or otherwise acting on behalf of the school. In these circumstances, these records are not education records subject to FERPA, even if the services are provided on school grounds, because the party creating and maintaining the records is not acting on behalf of the school. For example, the records created by a public health nurse who provides immunization or other health services to students on school grounds or otherwise in connection with school activities but who is not acting on behalf of the school would not be education records under FERPA. In such situations, a school that wishes to disclose to this outside party health care provider any personally identifiable information from education records would have to comply with FERPA and obtain parental consent. See 34 CFR 99.30. With respect to HIPAA, even where student health records maintained by a health care provider are not education records protected by FERPA, the HIPAA Privacy Rule would apply to such records only if the provider conducts one or more of the HIPAA transactions electronically, e.g., billing a health plan electronically for his or her services, making the provider a HIPAA covered entity. 4. Are there circumstances in which the HIPAA Privacy Rule might apply to an elementary or secondary school? There are some circumstances in which an elementary or secondary school would be subject to the HIPAA Privacy Rule, such as where the school is a HIPAA covered entity and is not subject to FERPA. As explained previously, most private schools at the elementary and secondary school levels typically do not receive funding from the U.S. Department of Education and, therefore, are not subject to FERPA. A school that is not subject to FERPA and is a HIPAA covered entity must comply with the HIPAA Privacy Rule with respect to any individually identifiable health information it has about students and others to whom it provides health care. For example, if a private elementary school that is not subject to FERPA employs a physician who bills a health plan electronically for the care provided to students (making the school a HIPAA covered entity), the school is required to comply with the HIPAA Privacy Rule with respect to the individually identifiable health information of its patients. The only exception would be where the school, despite not being subject to FERPA, has education records on one or more students to whom it provides services on behalf of a school or school district that is subject to FERPA. In this exceptional case, the education records of only those publiclyplaced students held by the private school would be subject to FERPA, while the remaining student health records would be subject to the HIPAA Privacy Rule. 5. Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a troubled teen to the parents of the teen? In most cases, yes. If the teen is a minor, the HIPAA Privacy Rule generally allows a covered entity to disclose PHI about the child to the child s parent, as the minor child s personal representative, when the disclosure is not inconsistent with state or other law. For more detailed information, see 45 CFR 164.502(g) and the fact sheet regarding personal representatives at: http://www.hhs.gov/ocr/hipaa/guidelines/personalrepresentatives.pdf. In some cases, such as when a minor may receive treatment without a parent s consent under applicable law, the parents are not treated as the minor s personal representative. See 45 CFR 164.502(g)(3). In such cases where 5 118

the parent is not the personal representative of the teen, other HIPAA Privacy Rule provisions may allow the disclosure of PHI about the teen to the parent. For example, if a provider believes the teen presents a serious danger to self or others, the HIPAA Privacy Rule permits a covered entity to disclose PHI to a parent or other person(s) if the covered entity has a good faith belief that: (1) the disclosure is necessary to prevent or lessen the threat and (2) the parent or other person(s) is reasonably able to prevent or lessen the threat. The disclosure also must be consistent with applicable law and standards of ethical conduct. See 45 CFR 164.512(j)(1)(i). In addition, the Privacy Rule permits covered entities to share information that is directly relevant to the involvement of a family member in the patient s health care or payment for care if, when given the opportunity, the patient does not object to the disclosure. Even when the patient is not present or it is impracticable, because of emergency circumstances or the patient s incapacity, for the covered entity to ask the patient about discussing his or her care or payment with a family member, a covered entity may share this information with the family member when, in exercising professional judgment, it determines that doing so would be in the best interest of the patient. See 45 CFR 164.510(b). 6. Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a student to a school nurse or physician? Yes. The HIPAA Privacy Rule allows covered health care providers to disclose PHI about students to school nurses, physicians, or other health care providers for treatment purposes, without the authorization of the student or student s parent. For example, a student s primary care physician may discuss the student s medication and other health care needs with a school nurse who will administer the student s medication and provide care to the student while the student is at school. 7. Does FERPA or HIPAA apply to records on students at health clinics run by postsecondary institutions? FERPA applies to most public and private postsecondary institutions and, thus, to the records on students at the campus health clinics of such institutions. These records will be either education records or treatment records under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule, even if the school is a HIPAA covered entity. See the exceptions at paragraphs (2)(i) and (2)(ii) to the definition of protected health information at 45 CFR 160.103. The term education records is broadly defined under FERPA to mean those records that are: (1) directly related to a student and (2) maintained by an educational agency or institution or by a party acting for the agency or institution. See 34 CFR 99.3, Education records. Treatment records under FERPA, as they are commonly called, are: records on a student who is eighteen years of age or older, or is attending an institution of postsecondary education, which are made or maintained by a physician, psychiatrist, psychologist, or other recognized professional or paraprofessional acting in his professional or paraprofessional capacity, or assisting in that capacity, and which are made, maintained, or used only in connection with the provision of treatment to the student, and are not available to anyone other than persons providing such treatment, except that such records 6 119

can be personally reviewed by a physician or other appropriate professional of the student s choice. See 20 U.S.C. 1232g(a)(4)(B)(iv); 34 CFR 99.3, Education records. For example, treatment records would include health or medical records that a university psychologist maintains only in connection with the provision of treatment to an eligible student, and health or medical records that the campus health center or clinic maintains only in connection with the provision of treatment to an eligible student. (Treatment records also would include health or medical records on an eligible student in high school if the records otherwise meet the above definition.) Treatment records are excluded from the definition of education records under FERPA. However, it is important to note, that a school may disclose an eligible student s treatment records for purposes other than the student s treatment provided that the records are disclosed under one of the exceptions to written consent under 34 CFR 99.31(a) or with the student s written consent under 34 CFR 99.30. If a school discloses an eligible student s treatment records for purposes other than treatment, the treatment records are no longer excluded from the definition of education records and are subject to all other FERPA requirements, including the right of the eligible student to inspect and review the records. While the health records of students at postsecondary institutions may be subject to FERPA, if the institution is a HIPAA covered entity and provides health care to nonstudents, the individually identifiable health information of the clinic s nonstudent patients is subject to the HIPAA Privacy Rule. Thus, for example, postsecondary institutions that are subject to both HIPAA and FERPA and that operate clinics open to staff, or the public, or both (including family members of students) are required to comply with FERPA with respect to the health records of their student patients, and with the HIPAA Privacy Rule with respect to the health records of their nonstudent patients. 8. Under FERPA, may an eligible student inspect and review his or her treatment records? Under FERPA, treatment records, by definition, are not available to anyone other than professionals providing treatment to the student, or to physicians or other appropriate professionals of the student s choice. However, this does not prevent an educational institution from allowing a student to inspect and review such records. If the institution chooses to do so, though, such records are no longer excluded from the definition of education records and are subject to all other FERPA requirements. 9. Under FERPA, may an eligible student s treatment records be shared with parties other than treating professionals? As explained previously, treatment records, by definition, are not available to anyone other than professionals providing treatment to the student, or to physicians or other appropriate professionals of the student s choice. However, this does not prevent an educational institution from using or disclosing these records for other purposes or with other parties. If the institution chooses to do so, a disclosure may be made to any party with a prior written consent from the eligible student (see 34 CFR 99.30) or under any of the disclosures permitted without consent in 34 CFR 99.31 of FERPA. 7 120

For example, a university physician treating an eligible student might determine that treatment records should be disclosed to the student s parents. This disclosure may be made if the eligible student is claimed as a dependent for federal income tax purposes (see 34 CFR 99.31(a)(8)). If the eligible student is not claimed as a dependent, the disclosure may be made to parents, as well as other appropriate parties, if the disclosure is in connection with a health or safety emergency. See 34 CFR 99.31(a)(10) and 99.36. Once the records are disclosed under one of the exceptions to FERPA s general consent requirement, the treatment records are no longer excluded from the definition of education records and are subject to all other FERPA requirements as education records under FERPA. 10. Under what circumstances does FERPA permit an eligible student s treatment records to be disclosed to a third-party health care provider for treatment? An eligible student s treatment records may be shared with health care professionals who are providing treatment to the student, including health care professionals who are not part of or not acting on behalf of the educational institution (i.e., third-party health care provider), as long as the information is being disclosed only for the purpose of providing treatment to the student. In addition, an eligible student s treatment records may be disclosed to a third-party health care provider when the student has requested that his or her records be reviewed by a physician or other appropriate professional of the student s choice. See 20 U.S.C. 1232g(a)(4)(B)(iv). In either of these situations, if the treatment records are disclosed to a third-party health care provider that is a HIPAA covered entity, the records would become subject to the HIPAA Privacy Rule. The records at the educational institution continue to be treatment records under FERPA, so long as the records are only disclosed by the institution for treatment purposes to a health care provider or to the student s physician or other appropriate professional requested by the student. If the disclosure is for purposes other than treatment, an eligible student s treatment record only may be disclosed to a third party as an education record, that is, with the prior written consent of the eligible student or if one of the exceptions to FERPA s general consent requirement is met. See 34 CFR 99.31. For example, if a university is served with a court order requiring the disclosure of the mental health records of a student maintained as treatment records at the campus clinic, the university may disclose the records to comply with the court order in accordance with the provisions of 99.31(a)(9) of the FERPA regulations. However, the mental health records that the university disclosed for non-treatment purposes are no longer excluded from the definition of education records and are subject to all other FERPA requirements as education records under FERPA. 11. Are all student records maintained by a health clinic run by a postsecondary institution considered treatment records under FERPA? Not all records on eligible students that are maintained by a college- or university-run health clinic are treatment records under FERPA because many such records are not made, maintained, or used only in connection with the treatment of a student. For example, billing records that a college- or university-run health clinic maintains on a student are education records under FERPA, the disclosure of which would require prior written consent from the eligible student unless an exception applies. See 34 CFR 99.30. In addition, records relating to treatment that are shared with persons other than professionals providing treatment to the student are education records under FERPA. Thus, to the extent a health clinic has shared a student s treatment information with 8 121

persons and for purposes other than for treatment, such information is an education record, not a treatment record under FERPA. 12. Does FERPA or HIPAA apply to records on students who are patients at a university hospital? Patient records maintained by a hospital affiliated with a university that is subject to FERPA are not typically education records or treatment records under FERPA because university hospitals generally do not provide health care services to students on behalf of the educational institution. Rather, these hospitals provide such services without regard to the person s status as a student and not on behalf of a university. Thus, assuming the hospital is a HIPAA covered entity, these records are subject to all of the HIPAA rules, including the HIPAA Privacy Rule. However, in a situation where a hospital does run the student health clinic on behalf of a university, the clinic records on students would be subject to FERPA, either as education records or treatment records, and not subject to the HIPAA Privacy Rule. 13. Where the HIPAA Privacy Rule applies, does it permit a health care provider to disclose protected health information (PHI) about a patient to law enforcement, family members, or others if the provider believes the patient presents a serious danger to self or others? The HIPAA Privacy Rule permits a covered entity to disclose PHI, including psychotherapy notes, when the covered entity has a good faith belief that the disclosure: (1) is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others and (2) is to a person(s) reasonably able to prevent or lessen the threat. This may include, depending on the circumstances, disclosure to law enforcement, family members, the target of the threat, or others who the covered entity has a good faith belief can mitigate the threat. The disclosure also must be consistent with applicable law and standards of ethical conduct. See 45 CFR 164.512(j)(1)(i). For example, consistent with other law and ethical standards, a mental health provider whose teenage patient has made a credible threat to inflict serious and imminent bodily harm on one or more fellow students may alert law enforcement, a parent or other family member, school administrators or campus police, or others the provider believes may be able to prevent or lessen the chance of harm. In such cases, the covered entity is presumed to have acted in good faith where its belief is based upon the covered entity s actual knowledge (i.e., based on the covered entity s own interaction with the patient) or in reliance on a credible representation by a person with apparent knowledge or authority (i.e., based on a credible report from a family member or other person). See 45 CFR 164.512(j)(4). For threats or concerns that do not rise to the level of serious and imminent, other HIPAA Privacy Rule provisions may apply to permit the disclosure of PHI. For example, covered entities generally may disclose PHI about a minor child to the minor s personal representative (e.g., a parent or legal guardian), consistent with state or other laws. See 45 CFR 164.502(b). 14. Does FERPA permit a postsecondary institution to disclose a student s treatment records or education records to law enforcement, the student s parents, or others if the institution believes the student presents a serious danger to self or others? 9 122

An eligible student s education records and treatment records (which are considered education records if used or made available for any purpose other than the eligible student s treatment) may be disclosed, without consent, if the disclosure meets one of the exceptions to FERPA s general consent rule. See 34 CFR 99.31. One of the permitted disclosures is to appropriate parties, which may include law enforcement or parents of a student, in connection with an emergency if knowledge of the information is necessary to protect the health or safety of the student or other individuals. See 34 CFR 99.31(a)(10) and 99.36. There are other exceptions that apply to disclosing information to parents of eligible students that are discussed on the Safe Schools & FERPA Web page, as well as other information that should be helpful to school officials, at: http://www.ed.gov/policy/gen/guid/fpco/ferpa/safeschools/index.html/. 15. Are the health records of an individual who is both a student and an employee of a university at which the person receives health care subject to the privacy provisions of FERPA or those of HIPAA? The individual s health records would be considered education records protected under FERPA and, thus, excluded from coverage under the HIPAA Privacy Rule. FERPA defines education records as records that are directly related to a student and maintained by an educational agency or institution or by a party acting for the agency or institution. 34 CFR 99.3 ( education records ). While FERPA excludes from this definition certain records relating to employees of the educational institution, to fall within this exclusion, such records must, among other things, relate exclusively to the individual in his or her capacity as an employee, such as records that were created in connection with health services that are available only to employees. Thus, the health or medical records that are maintained by a university as part of its provision of health care to a student who is also an employee of a university are covered by FERPA and not the HIPAA Privacy Rule. 16. Can a postsecondary institution be a hybrid entity under the HIPAA Privacy Rule? Yes. A postsecondary institution that is a HIPAA covered entity may have health information to which the Privacy Rule may apply not only in the health records of nonstudents in the health clinic, but also in records maintained by other components of the institution that are not education records or treatment records under FERPA, such as in a law enforcement unit or research department. In such cases, the institution, as a HIPAA covered entity, has the option of becoming a hybrid entity and, thus, having the HIPAA Privacy Rule apply only to its health care unit. The school can achieve hybrid entity status by designating the health unit as its health care component. As a hybrid entity, any individually identifiable health information maintained by other components of the university (i.e., outside of the health care component), such as a law enforcement unit, or a research department, would not be subject to the HIPAA Privacy Rule, notwithstanding that these components of the institution might maintain records that are not education records or treatment records under FERPA. To become a hybrid entity, the covered entity must designate and include in its health care component all components that would meet the definition of a covered entity if those components were separate legal entities. (A covered entity may have more than one health care component.) However, the hybrid entity is not permitted to include in its health care component other types of components that do not perform the covered functions of the covered entity or components that do 10 123

not perform support activities for the components performing covered functions. That is, components that do not perform health plan, health care provider, or health care clearinghouse functions and components that do not perform activities in support of these functions (as would a business associate of a separate legal entity) may not be included in a health care component. Within the hybrid entity, most of the HIPAA Privacy Rule requirements apply only to the health care component, although the hybrid entity retains certain oversight, compliance, and enforcement obligations. See 45 CFR 164.105 of the Privacy Rule for more information. VI. Conclusion The HIPAA Privacy Rule specifically excludes from its coverage those records that are protected by FERPA. When making determinations as to whether personally identifiable information from student health records maintained by the educational agency or institution may be disclosed, school officials at institutions subject to FERPA should refer to FERPA and its requirements. While the educational agency or institution has the responsibility to make the initial, case-by-case determination of whether a disclosure meets the requirements of FERPA, the Department of Education s Family Policy Compliance Office is available to offer technical assistance to school officials in making such determinations. For quick, informal responses to routine questions about FERPA, school officials may e-mail the Department at FERPA@ed.gov. For more formal technical assistance on the information provided in this guidance in particular or FERPA in general, please contact the Family Policy Compliance Office at the following address: Family Policy Compliance Office U.S. Department of Education 400 Maryland Ave. S.W. Washington, D.C. 20202-8520 You may also find additional information and guidance on the Department s Web site at: http://www.ed.gov/policy/gen/guid/fpco/index.html. For more information on the HIPAA Privacy Rule, please visit the Department of Health and Human Services HIPAA Privacy Rule Web site at: http://www.hhs.gov/ocr/hipaa/. The Web site offers a wide range of helpful information about the HIPAA Privacy Rule, including the full text of the Privacy Rule, a HIPAA Privacy Rule summary, over 200 frequently asked questions, and both consumer and covered entity fact sheets. In addition, if you would like to submit additional questions not covered by this guidance document or suggestions for purposes of informing future guidance, please send an e-mail to OCRPrivacy@hhs.gov and FERPA@ed.gov. 11 124

Nursing Care Quality Assurance Commission PO BOX 47864 i Olympia Washington 98504-7864 Tel: 360-236-4725i Fax: 360-236-4738 Job Titles/License Titles: Can a registered nurse work as a licensed practical nurse or a licensed practical nurse as a Nursing Assistant? Restructuring of health care delivery, and shifts in staffing mixes have led to interesting inquiries to the Boards of Nursing, registered nurses, licensed practical nurses, and employers have frequently consulted with Board staff about a registered nurse working as an licensed practical nurses or licensed practical nurses working as a nursing assistant. Questions also include other credentialed roles such as health care assistant. Sometimes licensing titles (registered nurse or licensed practical nurse) are being used interchangeably with work site job description designations. For example, a registered nurse may call and say, I have been offered a licensed practical nurse shift at the nursing home. Can I work as a licensed practical nurse? If that registered nurse is not also licensed as a licensed practical nurse, he or she may not call themselves a licensed practical nurse, nor sign documents as a licensed practical nurse. He can certainly assume the job responsibilities of a licensed practical nurse. What salary the nurse and employer agree to for compensation is an employer/employee issue not a licensure or titling issue. The same broad analysis applies to a licensed practical nurse considering working a position involving Nursing Assistant level responsibilities. Those responsibilities are included in the education, training, and scope of practice of the licensed practical nurse but the title is restricted to those persons registered or certified as nursing assistants. The registered nurse remains a registered nurse and the licensed practical nurse remains a licensed practical nurse even if working in a position that does not require that level of licensure. The Nursing Care Quality Assurance Commission regulates registered nurses, licensed practical nurses, and some components of nursing assistant regulation. The Commission does not manage the programs regulating health care assistants or any other credentialed professions/occupations. For assistance with any questions on requirements in those professions, call the Nursing Practice Advisor at 360-236-4725 or email: Nursing@doh.wa.gov 190

Department of Health Nursing Care Quality Assurance Commission Interpretive Statement Revised 10/18/11 Title: Patient Abandonment Number: NCIS 1.0 References: Regulation of Health Professions Uniform Disciplinary Act (RCW 18.130) http://apps.leg.wa.gov/rcw/default.aspx?cite=18.130 Violations of Standards of Nursing Conduct or Practice (WAC 246-840-710): http://apps.leg.wa.gov/wac/default.aspx?cite=246-840-710 Nursing Care (RCW 18.79) http://apps.leg.wa.gov/rcw/default.aspx?cite=18.79&full=true Contact: Deborah Carlson, RN, MSN Nurse Practice Advisor Phone: (360) 236-4725 Email: debbie.carlson@doh.wa.gov Effective Date: November 16, 2012 Supersedes: Patient Abandonment Policy A13.05 Approved By: Nursing Care Quality Assurance Commission Statement Nurse Technicians, Licensed Practical Nurses, Registered Nurses, and Advanced Registered Nurse Practitioners who abandon patients are in violation of the Standards of Nursing Conduct of Practice, WAC 246-840-700. The Nursing Care Quality Assurance Commission (Commission) concludes that patient abandonment occurs when a nurse, who has established a nurse-patient relationship, leaves the patient assignment without transferring or discharging nursing care in a timely manner. This applies in any health care setting; it applies to paid or unpaid nursing care. Employee problems do not constitute patient abandonment. Background The Commission establishes, monitors, and enforces standards of practice, RCW 18.79.010. The Commission interprets that a nurse-patient relationship begins when the nurse accepts assignment for nursing care. Assignment includes the patient care functions that the nurse is responsible to perform. A person authorized to administer, supervise, or direct the nurse may make the assignment. A nurse may accept a patient assignment based on professional judgment or through a contractual relationship. The Uniform Disciplinary Act (UDA), RCW 18.130, describes procedures for discipline. The Commission gets many complaints about employee problems. These are not subject to discipline by the Commission. 191

In compliance with WAC 246-840-700, transferring nursing care must include reporting (oral or written) of the patient s condition, circumstances, and care needs to an appropriate caregiver. As defined in RCW 18.79.260, an appropriate caregiver is a licensed health professional whose scope of practice and qualifications permit transferring functions and responsibilities. In some settings, the nurse may also transfer care to an appropriate family member or other designated caregiver in some settings. The caregiver must accept the transfer of care and understand the report. Examples of Patient Abandonment Ending a contractual relationship as the primary provider Leaving an emergency situation Leaving the patient care setting Leaving the patient in an unsafe situation to give care to an unassigned patient Failing to report suspected abuse or neglect Sleeping on duty Giving care while impaired Giving care incompetently Delegating care to an unqualified caregiver Failing to supervise staff carrying out delegated tasks Failing to give appropriate care Failing to perform assigned patient responsibilities Failing to give appropriate information when transferring or discharging care Failing to notify an appropriate person about significant changes Failing to communicate or document information Examples of Employee Problems Failing to call in, show up, or arrive late for an assigned shift Refusing to work, refusing to work extra hours, or not returning from, a scheduled absence Resigning at the end of a shift, without advanced notice, or not working the remaining posted work schedule Refusing to work in a setting because of inadequate orientation, education, training, or experience Refusing to work in an unsafe situation Refusing to perform care that may be harmful to the patient Refusing to delegate a task to an unsafe caregiver Refusing an assignment because of ethical, religious, or cultural reasons Conclusion Patient abandonment violates the Standards of Nursing Conduct of Practice, WAC 246-840-700. This occurs when: The nurse establishes a nurse-patient relationship by accepting a nursing assignment, and The nurse ends the nurse-patient relationship without transferring or discharging responsibilities to an appropriate caregiver in a timely manner. Examples help explain the difference between patient abandonment and employee problems of which the Commission does not have authority over. 192

Nursing Care Quality Assurance Commission PO BOX 47864 i Olympia Washington 98504-7864 Tel: 360-236-4725i Fax: 360-236-4738 Questions of Assignment Questions from nurses, supervisors, employers, etc., frequently arise regarding delegation of assignments and refusal of assignments. Floating is frequently expressed as an area of concern. Nurses may feel incompetent to fill in on units with which they are unfamiliar (especially critical care units). Sometimes nurses are asked to take more responsibility than they feel competent to handle (i.e. being asked to be in charge of an unfamiliar unit). Nurses may also feel that their assignment is too heavy and may be required to work overtime or double shifts when they feel mentally and/or physically fatigued. Nurses may be asked to do a specific task or procedure that they do not feel qualified to perform or that they believe is beyond their scope of practice. The situations that arise are many and varied. There are no clear-cut answers or solutions and the majority of these types of situations should be resolved through cooperative efforts of the parties involved at the employment setting. There are, however, laws, rules and regulations that all nurses should be aware when trying to resolve this type of situation (RCW 18.130.080, WAC 246-840-710). Unprofessional conduct is grounds for disciplinary action against a nursing license. Some of the grounds that relate specifically to assignments are: Failure to utilize appropriate judgment in administering safe nursing practice including failure to supervise those to whom nursing activities have been delegated. Incompetence, negligence or malpractice, which results in injury to a patient or which creates a risk that a patient may be harmed. Performing acts beyond the scope of practice for which the nurse is licensed. Performing nursing techniques or procedures for which the nurse lacks knowledge, experience, and education without instruction, supervision, and/or consultation. Delegating nursing care, functions, tasks or responsibilities to others who the nurse knows or has reason to know lacks the ability or knowledge to perform or delegating to unlicensed persons those functions or responsibilities, which are to be performed only by licensed persons. Leaving a patient care nursing assignment without notifying personnel so that reasonable arrangements for continuation of care can be made when continued nursing care is required by the condition of the patient. 193

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