Confidentiality health records and duty to report
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Confidentiality, Health Records, and Duty to Report. Cindy Greenberg OSAH Clinical Nurse Consultant NM Department of Health Office of School & Adolescent Health [email protected] 505-222-8680. Objectives.

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Confidentiality health records and duty to report

Confidentiality, Health Records, and Duty to Report

Cindy Greenberg

OSAH Clinical Nurse Consultant

NM Department of Health

Office of School & Adolescent Health

[email protected]

505-222-8680

Cynthia Greenberg, RN, BSN, MSN, NCSN


Objectives
Objectives

  • Describe guidelines for maintaining the confidentiality of student health information.

  • Identify indicators of child abuse/neglect and the duty to report.


What is confidential information
What is confidential information?

All health information should be considered confidential including verbal, written, and electronic health information.


Confidentiality verbal communication
Confidentiality – Verbal Communication


Verbal information
Verbal Information

  • Foundational to our health is safety.

  • Healing and health happen together.

  • “Sacred information”

  • Anythinga student says to the school health assistant or the nurse is kept confidential.

  • Few exceptions


Exceptions
Exceptions

Possibility the student is or will:

  • Harm self

  • Harm others

  • Is being harmed or abused



Written information
Written Information Records

  • Write so we can all read it – only use agreed upon abbreviations, no texting language

  • Use a pen – black ink preferable

  • Use standard medical abbreviations

  • Date and sign each entry note

  • Report what you observe

    -avoid judgments and opinions

  • To correct a mistake:

    - Draw a line through error and initial.

    - Do not erase or use white out

“Just the facts, Ma’am”


Legally speaking if it isn t documented it was not done
Legally speaking: RecordsIf it isn’t documented, it was not done!!!!



Student health information
Student Health Information: Records

  • Provided by the parent or guardian

  • Includes all pertinent health and family history

  • Obtained when the student first registers with a school district and is updated each year



Student health record file
Student Health Record/File Records

  • Medication order/permission form

  • Emergency information

  • Original accident report

  • Screening, referrals, and follow-up information

  • Screening for Special Ed.

  • Medical /Health history/ IHPs

  • PE or other class restrictions or exemptions

  • Health evaluations from outside medical providers & agencies

  • Confidential release forms

  • Immunization record or exemptions

  • Must be stored safely and securely.


How long are schools required to keep student health records
How long are schools required to keep student health records?

[NMAC 1.20.2.101] The student health record includes but is not limited to health history, immunization record, results and recommendations from medical examinations, medical orders, screenings, treatments, parent or guardian referral record, teacher comments, etc.

Must be retained: 10 years after date of last entry or until student attains age 19, whichever is longer.


Child abuse
Child Abuse records?

Reporting


Types of abuse
Types of Abuse records?

  • Physical

  • Emotional

  • Sexual

  • Neglect


Child abuse reporting
Child Abuse Reporting records?

The NM Children’s Code 32A-4-3 states:

Any person who SUSPECTS or HAS KNOWLEDGE that a child is being abused or neglected is mandated to report to:

  • Local Law Enforcement

  • Child Protective Services or

  • Tribal Law Enforcement


Nm statewide central intake 1 800 797 3260
NM Statewide Central Intake records? 1-800-797-3260

From a cell phone:

Text #SAFE (#7233) or

Call 1-855-333-SAFE

to report suspected child abuse or neglect

Albuquerque: 841-6100


Required information
Required Information: records?

  • Child’s name, age, & date of birth

  • Current location

  • Parent/guardian name & address

  • Name of siblings also at risk

  • Name of alleged perpetrator and location

  • Description of concerns


Stories and questions
Stories and Questions: records?

REMEMBER:

Do not hesitate to report because of lack of information—

if you suspect abuse, the information you have is valuable!



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