Documentation and Record Keeping
Health Services Documentation

The school health record is an official document that is the assembly of written and electronic records to describe health care provided and the reasons for providing care. It is essential for communication with health care providers and families. It describes the collaboration and coordination that occurs and provides continuity of care. It should also be a direct reflection of the professional nursing practice that is provided.

The value of the student health record lies in the information it contains and the way it is used. An effective written account of the facts and events related to the student’s health. The health record must be accurate, cumulative, specific, objective, and private.

Minnesota Statute 144.29, Health Records: Children of School Age, outlines the responsibility of all schools to keep a permanent public health record for every student. It needs to be kept in a way that can be transferred with the student if they transfer within the state. It also requires that the record contain the health data defined in Minnesota Statute Chapter 13.32, subdivision 2. There are many additional details of this statute that should be considered when developing a school policy.

Besides the requirement to keep records, school districts must also adhere to MN Chapter 13. Government Data Practices regarding collection, classification, handling, review, dissemination, and destruction of data. The general classification system of government data is a way of delineating who is authorized to have access to information. For purposes of school health services provided to students, all health service personnel should become familiar with the classification of data on individuals, further subdivided into public, private and confidential data.  

The MN Department of Administration provides additional information on Data Practices and MN Chapter 13 which applies to school districts. School health services personnel are encouraged to work with school leaders and school legal counsel for application or interpretation specific to the school district.

It is important for districts to establish policies regarding school health records. This policy should include:

• Clearly defined method for adding and including additional information and documents to the record.
• A description of who is responsible for the maintenance of the record
• How records will be kept secure, both physically and electronically
• A method for the closure and transfer of the record
• A standardized and accepted list of abbreviations
• A record retention schedule

How is the School Health Record Used?

The uses of the health record include:

• Documentation of the health services provided and the outcomes of that care by the school nurse and other school staff.
• Description of student health history and health conditions
• Organizing, collecting, and storing of the health information for student health care plans
• Means of providing information and care for a student in a health emergency
• Providing accountability to students, parents and guardians about the care provided
• Providing information for supervisory and peer audits for quality improvement
• Providing data to inform decision making related to school health programs.
• Continuity of care for changes in schools or staffing
• Making referrals to other health care providers and coordinating care with other partnering agencies
• Provides a legal record of care.

What is Included in the Student Health Record?

Minnesota Statute Chapter 13.32, Subdivision 2 highlights elements that must be kept in the health record, which is part of the educational record:

• Health data concerning students, including but not limited to, data concerning immunizations, notations of special physical or mental problems and records of the school nurse.
• Pupil census data, including emergency information and family information.
• Data concerning parents and private data on individuals but may be treated as directory information if the same procedures that are used to designate student data as directory data under subdivision 5 are followed.

Additionally, the health record should include:

• Early childhood screening information should be kept in the student health file as well, per Minnesota Statute Chapter 121A.17.
• Student visits to the health Office
• Medical, laboratory or therapy reports
• Medication or treatment orders from a health care provider
• Parental consents
• Health care plans
• Health related correspondence

Third Party Billing

The Minnesota Department of Human services does require Record keeping and Documentation for any school district enrolled and billing for health related services. School nurses should work with school leaders who are responsible for the third party billing program in their school or district to make sure the documentation system being used will meet the requirements.

The school health record is a legal document. The health office should establish clearly written guidelines and expectations for all health services staff. Best practices in documentation include:

• Confidential information only accessible to those with "legitimate right to know" as described by Federal Educational Right to Privacy Act (FERPA). More information about FERPA can be found in Data Privacy.
• Accurate, objective, concise information.
• Correct grammar, spelling and punctuation.
• Well organized in a way that is systematic and allows for information to be retrieved.
• Only using abbreviations that are on the district's list of standard abbreviations.
• Date (including year) and time of the care provided.
• Date (including year) and time of the documentation, if provided at a different time than care was provided noting that it is a “late entry”. *All documentation should be entered as soon as possible following delivery of care to decrease risk of error.
• Signature and title of the person providing care.
• Title can be abbreviated using standard abbreviations (i.e., RN, LPN, UAP).
• Use quotation marks to indicate the exact words used when appropriate.
• Only documenting objective information about the encounter.
• Entries should be comprehensive and reflective of the providers full scope of practice.
• Including all relevant statistics, observations or assessments, actions taken and outcomes
• Specific description and outcome of the treatment, procedure, or medication provided.
• The date and time of any contacts made on the student’s behalf, who you contacted (i.e., parent, providers) and method of contacting them (i.e., email, phone).
• Record referrals completely and specifically.
• An ongoing record of who has reviewed the health record including date and full name of the person reviewing.

Districts may use electronic or paper documentation systems or even a combination of both. Depending on what type of system a district uses, specific details should be considered.

Paper documentation

• Legible.
• Written in blue or black ink.
• No erasing or use of white out.
• A single line through the entry is made when there is an error, so that the original information can be read. The word "error," the signature of the person making the correction and the date of the correction should be written at the closest point possible to the correction.
• No blank lines between the entries, if a blank line is accidentally left, draw a line through the center of any unused lines.
• Kept in a central, locked location.

Electronic Documentation

• No erasing, ensure that the data system captures the original entry and documents who and when the correction was made, with a place for entering why the correcting is being made.
• Password protected and a policy that determines the frequency of password changes.
• If using an electronic signature, ensure that it is spelled correctly, with accurate licensure or title attached.
• Overwrite protection.
• Strong back up system.

The National Association of School Nurse has a position statement Electronic Health Records: An Essential School Nursing Tool for Supporting Student Health which provides additional information.

Minnesota Statute 144.29 "...at the beginning of each school year the health record of all pupils shall be reviewed by a teacher, school nurse or other professional person".  Record review is an essential component of health record maintenance. It helps to assure that all charting is being done according to established policies and procedures. If a record review reveals that documentation is not being done according to policy, prompt corrective action to improve documentation procedures is appropriate.

Each school should have a person who is designated as the responsible authority regarding record retention and sets up the record retention schedule. If the school does not set up their own record retention schedule they can adopt the general district general record retention schedule for school districts.

Minnesota Department of Education Q&A: Record Retention and Record Retention Schedules provides additional information.

Communicating with Others Within the School

There may be circumstances where information in the student record may need to be shared with certain school personnel to enhance the educational progress of the student or protect his/her safety or well-being. Staff may need to be alerted to signs or symptoms of a medical problem and offer a course of action. Information in the student health record, however, may be shared with appropriate school personnel as necessary to protect the well-being or safety of the student. This is considered "legitimate right to know."

The Minnesota Department of Education has a document that can provide additional information. Q & A: Protecting the Privacy of Student Educational Records and Personally Identifiable information.

In accordance with the law, local policies and professional standards, the school nurse has the specialized skill, judgment, and knowledge to decide which health information is educationally relevant and the school personnel requiring that information. Sharing the school health/education information for any other purpose is inappropriate and unethical. Mishandling of data could

It is important to carefully document who has reviewed the school health record. A log should be kept with the record indicating who has had access to the record and when.

Communicating with Others Outside of the School

Schools may share the education record with another school per MN Statute 123B.08 Flag Records of Missing Children but releasing records to most other organizations will require a signed parental/guardian release of information. If you are unsure, consult with school leaders or legal counsel.

Sharing immunization records is governed by section 121A.15, subdivision 7 states “when a person transfers to another elementary or secondary school or child care facility, the administrator or other person having general control and supervision of the school or child care facility shall assist the person's parent or guardian in the transfer of the immunization file to the person's new school or child care facility within 30 days of the transfer. Upon the request of a public or private postsecondary educational institution, as defined in section 135A.14, the administrator or other person having general control or supervision of a school shall assist in the transfer of a student's immunization file to the postsecondary institution.”

Student health information can also be disclosed MN Statute 13.32 Subd. 3 (f) “to appropriate health authorities to the extent necessary to administer immunization programs and for bona fide epidemiologic investigations which the commissioner of health determines are necessary to prevent disease or disability to individuals in the public educational agency or institution in which the investigation is being conducted”.