DEPARTMENT OF EDUCATION

Office of the Secretary

FINAL

REGULATORY IMPLEMENTING ORDER

811 School Health Record Keeping Requirements

I. SUMMARY OF THE EVIDENCE AND INFORMATION SUBMITTED

The Secretary of Education intends to amend 14 DE Admin. Code 811 School Health Record Keeping Requirements. This regulation is being amended to clarify procedures and purpose of school health record keeping documents.

Notice of the proposed regulation was published in the News Journal and the Delaware State News on October 1, 2015, in the form hereto attached as Exhibit “A”. Comments were received from the State Council for Persons with Disabilities (SCPD) and the Governor’s Advisory Council for Exceptional Citizens (GACEC) and a public school nurse. Comments included: (1) clarification needed for the meaning of “issued medications”, and are they “prescribed” or “non-prescribed”. The Department clarified this by adding the words “or prescribed”; (2) further clarification needed for “mandated testing and screenings”. The Department deleted the word “mandated”; (3) further clarification needed to “Delaware School Health Record” to include “student athlete health records required by DIAA regulation”. The Department agrees with this change and included that specific language for clarification; (4) request to add an email address in the definition of “Emergency/Nursing Treatment Card” as to identify classes of individuals. The Department did not make this change as the card contains the minimum information needed. A school district can add additional information if it wishes to do so; (5) expansion of definition of “parent” to include “parent, guardian or Relative Caregiver” to be consistent with other regulations. The Department added 'guardian or Relative Caregiver' where needed to include those relationships. Lastly, there was a general comment about how the amended regulation would impact school nurses. There will be no changes in practice due to this amended regulation, as the amendments are made to clarify procedures and further articulate expectations.

II. FINDINGS OF FACTS

The Secretary finds that it is appropriate to amend 14 DE Admin. Code 811 School Health Record Keeping Requirements in order to clarify procedures and purpose of school health record keeping documents.

III. DECISION TO AMEND THE REGULATION

For the foregoing reasons, the Secretary concludes that it is appropriate to amend 14 DE Admin. Code 811 School Health Record Keeping Requirements. Therefore, pursuant to 14 Del.C. §122, 14 DE Admin. Code 811 School Health Record Keeping Requirements attached hereto as Exhibit “B” is hereby amended. Pursuant to the provision of 14 Del.C. §122(e), 14 DE Admin. Code 811 School Health Record Keeping Requirements hereby amended shall be in effect for a period of five years from the effective date of this order as set forth in Section V. below.

IV. TEXT AND CITATION

The text of 14 DE Admin. Code 811 School Health Record Keeping Requirements amended hereby shall be in the form attached hereto as Exhibit “B”, and said regulation shall be cited as 14 DE Admin. Code 811 School Health Record Keeping Requirements in the Administrative Code of Regulations for the Department of Education.

V. EFFECTIVE DATE OF ORDER

The actions hereinabove referred to were taken by the Secretary pursuant to 14 Del.C. §122 on November 19, 2015. The effective date of this Order shall be ten (10) days from the date this Order is published in the Delaware Register of Regulations.

IT IS SO ORDERED the 19th day of November 2015.

Department of Education

Steven Godowsky, Secretary of Education

Approved this 19th day of November 2015

811 School Health Record Keeping Requirements

“Delaware School Health Record Form” means an form electronic document containing documentation of an information about a student’s health information, which includes but is not limited to identifying information, health history, the student’s name, gender, birthdate, immunizations, results of [mandated] testing and screenings, medical diagnoses, long term issued [or prescribed] medications and treatments, [student athlete health records compiled in compliance with DIAA regulations] and referrals.

“Department” means the Delaware Department of Education.

“Emergency/Nursing Treatment Card” means a card form containing contact information and general school emergency procedures for the care of a student who becomes sick or injured at school. The card contains the following information: the student's name, birth date, school district, school, grade, home room or teacher or class assignment, home address, home and telephone number,; the name, place of employment and work telephone number of the parent, guardian or Relative Caregiver; two other names, addresses, and telephone numbers of individuals who can be contacted at times when the parent, guardian or Relative Caregiver can not cannot be reached; the name and telephone number of the family physician primary health care provider and family dentist; any medical conditions or allergies the student has; and the student's medical insurance.

“Student Accident Report Form” means a form developed by the Department that is used by the district or charter to review school accidents resulting in medical evaluation or referral.

“Student Health History Update” means a form developed by the Department that is used to obtain current student health information from the parent, guardian, or Relative Caregiver or the student if 18 years or older or an unaccompanied homeless youth.

“Summary of School Health Services” means an annual report created by the Department on school health services that have been provided and electronically documented by school nurses.

2.1 An Emergency/Nursing Treatment Card for each public school student shall be on file in the office of the school nurse.

2.1.1 The information on the Emergency/Nursing Treatment Card shall be shared only on a need to know basis as related to the education and health needs of the student and consistent with state and federal laws.

2.1.2 The parent, guardian or Relative Caregiver or the student if 18 years or older, or an unaccompanied homeless youth (as defined by 42 U.S.C. 11434(a)) shall sign the Emergency/Nursing Treatment Card to assure they understand the purpose of the form and acknowledge the accuracy of the information.

2.1.3 The Emergency/Nursing Treatment Card is used to update the student’s medical information on the Delaware School Health Record and student’s contact information in the district or charter electronic pupil accountability system.

2.1.4 The contact information on the Emergency/Nursing Treatment Card shall be used by the school nurse to contact the parent[, guardian or Relative Caregiver] regarding any health-related matter and to identify a person to pick up or provide consultation regarding the student’s acute illness or injury.

3.1 The Delaware School Health Record Form shall be current and shall be part of the student’s health record within the Cumulative Record File (14 DE Admin. Code 252) which accompanies the student when he or she moves to another school.

3.2 The Delaware School Health Record Form shall be maintained for the duration of the student's schooling and the school nurse shall use the Student Health History Update Form to keep health records current. The Delaware School Health Record Form shall remain in the nurse's file during the student's attendance in school.

3.2.1 The Delaware School Health Record Form may shall be maintained in hard copy or within an electronic documentation program and transferred electronically with the student. If the Delaware School Health Record cannot be transferred electronically, a hard copy shall be created and transferred to the receiving school. Beginning with the 2008-2009 school year, all Delaware School Health Records Forms shall be in an electronic format.

3.3 Documentation received on the student’s health, including parent medication permission slips and immunization records, shall be recorded in his or her electronic Delaware School Health Record. Hard copies of the documents shall be maintained in an individual school health folder.

NON REGULATORY NOTE: also see 14 DE Admin. Code 251 and 252 and the Delaware Public Archives Document Delaware School Districts General Records Retention Schedule.

4.1 The school nurse shall document in the state, district, or charter electronic health record system for individual student health data any nursing care provided including the school name, a three point date, the person's (student, staff or visitor) first and last name, the time of arrival and departure, the presenting complaint, the nurse's assessment intervention and the outcome, including the disposition of the situation, the parent or other contact, if appropriate, and the nurse's complete signature or initials.

4.1.1 The school nurse shall document the care given at the time of a school based accident by completing the Student Accident Report Form if the student missed more than one half day because of the accident or if the school nurse has referred the student for a medical evaluation regardless of whether the parent, guardian or Relative Caregiver or student if 18 years or older, or an unaccompanied homeless youth (as defined by 42 U.S.C. 11434(a)) followed through on that request.

5.1 All local school districts and charter schools shall submit the Summary of School Health Services Form, to the Delaware Department of Education by August 31st of each year. The form shall include all of the school health services provided in all schools during the fiscal year including summer programs. The Department will annually create the Summary of School Health Services provided by districts and charters. Data from the previous school year shall be collected from the state’s pupil accountability system after August 15th. Any district or charter using an alternative electronic health record shall submit an electronic version of the Summary of School Health Services report to the Department by August 31st of each year.