School Nursing: Documentation, Recordkeeping ..., Study notes of Nursing

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School Nursing:

Documentation,

Recordkeeping,

Confidentiality

Colorado Department of

Education

June 2005

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Overview

School nurses are privy to a great deal of intimate information about the students with whom they work. The increased number of children in schools with health and learning challenges has resulted in more than the traditional screening and immunization information in a student's health records.

A complex web of laws and standards of professional practice define the responsibilities and rights of parents, students, school health staff and other school staff in the creation, updating, maintenance, control of, access to, and disclosure of student health records. Education reforms, such as inclusion, accountability, charter schools, homeless and migrant education, and safe schools may mean that schools will need to create more data about their students and consider whether and how to share it, both exclusively within the school setting and between the school and other organizations. Budgetary realities mean that fewer schools have only one person with day- to-day “control” of all health information about students. Increasing electronic technology for encoding, storing, and transmitting of data has resulted in new and heightened privacy concerns.

A school’s need to document and share student health information must be considered against the student’s rights to confidentiality for sensitive services or unwarranted disclosure of personal information and the parent’s and student’s rights to know what is in a student’s record, to gain access to it for inspection or correction, and to control disclosure of that information.

This chapter discusses responsibilities of school staff in creating health records about a student, maintaining those records, and disclosing or sharing the information contained in those records. It also discusses the rights of parents and students in accessing these records and their rights to control release of these records.

School nurses may be the authors and/or custodians of many formal, legally mandated health records, such as Individualized Family Service Plans (IFSPs); Individualized Health Plans (IHPs), Individualized Emergency Plans, (IEPs), etc. Their files contain notes on individual students seen during the course of the school year, a student's medications, notes about the physical or mental health condition of a student or even a student’s parents, reasons for

Disclosure of student health information includes disclosures to the student, the student’s parents, school staff, and other non-school third parties

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Legal Considerations

This section briefly describes the pertinent legislation and then goes through the "life stages" of a record, with the requirements of each particular law.

Privacy, Access and Disclosure

• Family Educational Rights & Privacy Act (FERPA)^1 The Family Educational Rights and Privacy Act (FERPA, sometimes called the "Buckley Amendment") is a federal law designed to protect the privacy of student education records that are maintained by a school. School health records are considered to be part of a student’s educational record. The law applies to all schools receiving federal funds from the United States Department of Education. Basically, the law gives parents the right to inspect and review their child's educational records, to amend errors or inaccuracies in those records, and to consent to disclosure of those records. These rights transfer to the student, or former student, who has reached the age of 18 or is attending any school beyond the high school level. Health information that will further a student’s academic achievement and/or maintain a safe and orderly teaching environment may be accessed by school staff

(^1) 20 USC §1232g; regulations are found in 34 CFR Part 99.

who have a specific and legitimate educational interest in the information. The school must maintain a written log of who accessed the records and when access occurs. 2

• The Individuals with Disabilities Education Act (IDEA) of 1990, 1997, and 2004; and the Americans with Disabilities Act (ADA) of 1990, and Section 504 of the Rehabilitation Act of 1973 ; These laws require schools to create certain health records about children with special health care needs..^3 IDEA goes beyond FERPA with respect to records of children with disabilities who are eligible for special education services, and it guarantees parents the right to inspect and review all education records relating to their child that a public agency collects, maintains, or uses regarding the identification, evaluation, and educational placement and assures the provision of a “free and appropriate public education” (FAPE) to the child.^4 IDEA also broadens the definition of a parent who can have access to records by including persons acting in the place of a parent or legal

(^2) National Center for Educational Statistics (1997). Guidelines for protecting confidential student health information. Kent, OH: American School Health Association. 3 IDEA's regulations on confidentiality 34 CFR §§300.560-300.577 contain several references to FERPA. 4 34 CFR §§ 300.501 and 300.562.

School health records are considered to be part of a student’s educational record

FAPE - Free and Appropriate Public Education

FERPA- Family Educational Records Privacy Act

HIPAA- Health Information Portability and Accountability Act

IDEA- Individuals with Disabilities Educational Act

LRE – Least Restrictive Environment

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Legal Considerations

guardian or who might be legally responsible for a child's welfare, such as a grandmother, stepparent, or foster parent.

• Health Insurance Portability and Accountability Act (HIPAA) 5 The Health Insurance Portability and Accountability Act (HIPAA), is a federal law requiring health care providers to keep confidential personally identifiable health records. The law covers individual health plans, health information, health clearinghouses, and health care providers that transmit health- related information electronically. Health care providers are providers (or suppliers) of medical or other health services or supplies. Because schools are not considered to be health entities, and because FERPA is as or more restrictive than HIPAA, schools are generally not bound by HIPAA regulations. The Office for Civil Rights at HHS, which administers the HIPAA regulations, has said that "individually identifiable health information of students under the age of 18 created by a nurse in a primary [elementary] or secondary school that receives federal funds and that is subject to FERPA is an education

(^5) Health Insurance Portability and Accountability Act of 1996, Privacy Amendment Regulations, 45 CFR Parts 160 and 164, http://www.hhs.gov/ocr/hipaa/finalreg.html.

record, but not protected health information." 6

There are several instances in which HIPAA does impact schools. School based health centers, that are operated under the auspices of a hospital or health center must comply with the regulations that govern that organization and therefore must comply with HIPAA regulations. School districts that bill for Medicaid reimbursement must comply with HIPAA regulations because of the electronic dissemination of information from the school to billing agents and the state. And health care practitioners that share information with schools must comply with HIPAA requirements. This fact may lead to frustration on the part of schools when health care practitioners refuse to release information without the releases that they have in place. Sharing of immunization information, however, is not governed by HIPAA regulations. Schools are acting as a “public health authority” when they are statutorily required to track the immunization status of children at the school. HIPAA allows protected health information to

(^6) HIPAA regulations, which became effective in 2003, also do not apply to FERPA records designated as education records under Parts B, C, and D or the Individuals with Disabilities Education Act (IDEA); Memorandum from. Family Policy Compliance Office, U.S. Department of Education. (February 2002).

The exclusion of school health records from HIPAA regulations is explained by the fact that FERPA already protects those records and no further protection is deemed necessary

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Legal Considerations

The Life Stages of a School Health Record The life stage of a record includes its creation, its maintenance and storage, limitations to access of the record, and retention after the student leaves the school program_._

What is a Record? FERPA protects eligible students' privacy interests in "education records," which are defined as "those records, files, documents, and other materials which - (i) contain information directly related to a student; and (ii) are maintained by an educational agency or institution or by a person acting for such agency or institution.”^12 The rights under FERPA belong to the parents of students under the age of 18 at the elementary/ secondary level and transfer to the student when he or she becomes an "eligible” student at age 18.

Under FERPA and Colorado law , education records include information directly related to a student, which are maintained by the school in any recorded way, such as test scores, disciplinary records, transcripts, etc. They do not include records made by school personnel that are kept solely in their own possession and are not revealed to anyone

(^12) 20 USC §1232g(a)(4)(i) and (ii); see also 34 CFR § 99.3.

else. A school nurse’s personal notes or diary would not be an official school health record, unless the nurse shared them with others as part of her work. 13

Federal and state laws generally prohibit disclosure of information in the record without the consent of the parent or eligible student. There are exceptions. Disclosure without prior consent is permissible under limited circumstances:

• to other school officials, including teachers, who have specific and legitimate educational interests in the information for use in furthering the student's academic achievement or maintaining a safe and orderly learning environment;
• to officials of a school at which the student seeks or intends to enroll;
• to state or local officials or authorities if the disclosure concerns the juvenile justice system;
• to comply with a judicial order or a lawfully issued subpoena, after a reasonable effort is made to notify the student's parent or legal guardian in advance; and
• in connection with an emergency if the information is necessary to protect the health

or safety of the student or

other individuals.

(^13) 20 USC §1232g(4)(B).

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Legal Considerations

In Colorado, if a school creates or collects medical or health records on a student, those records are considered the student's Cumulative Health Record (CHR), and they are part of the student's academic record. The CHR contains:

• the student record card with health history;
• summary of relevant health office interactions including significant accidents and illnesses, and summary of medications given (including the name of the medication, dosages, and start and stop dates);
• the latest individualized health care plan;
• most recent and completed immunization record;
• results, recommendations, and follow-up related to all screening; and,
• other information that is deemed relevant by the school nurse. 14

Who Creates School Health Records? Since school staff members other than the school nurse contribute to a student’s health needs, it follows that they could also contribute to a school health record. Staff who might contribute to the record could include education support professionals (including

(^14) Colorado Department of Education (2004). Record retention. http://www.cde.state.co.us/cdesped/nurseFA Q.asp

registered nurse, licensed practical nurse, nurses’ aide, classroom staff, health or therapist aide/technician); outside health provider; school psychologist; or school social worker. Because this pool of possible contributors is so wide, the school should have a clearly articulated system of how records are created and templates for reporting, so data is kept in a coherent fashion. For example, dates and names should be written in consistent formats, full name of recorders should be included in the record, and the school nurse should have overall responsibility for the records.

Maintenance and Storage of Records Storage and maintenance of records involve active records and historical records. The active records in the school nurse’s office, whether they are paper or electronic, need to be secure when not in use, but accessible when needed by staff. Lockable filing cabinets or computers are important, but maintaining these documents in a safe and monitorable location is also essential.^15

(^15) Policy Studies Associates, Inc. under contract to the Council of Chief State School Officers. Protecting the Privacy of Student Records Guidelines for Education Agencies National Center for Education Statistics: 1997 http://nces.ed.gov/pubs97/p97527/Sec5_txt.h tm

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Legal Considerations

Under both federal and state laws, parents must be informed annually of their rights of access, ability to limit disclosures, and ability to have knowledge of third party access to their child’s records.

Who Else Can Have Access? Generally under FERPA a school cannot release information, other than “directory information” from a student's record without prior written permission from the parent or the eligible student. 21 Disclosure of “directory information” without prior written consent is allowed. “Directory information” is information that would not generally be considered harmful or an invasion of privacy if disclosed.

FERPA and Colorado laws allow disclosure of other information in a student’s records , without consent , in certain specific situations:

• To school employees who have a need to know based on the “legitimate educational interests” of the student;
• To other schools to which a student is transferring;
• To certain government officials in order to carry out lawful functions;

(^21) USC §1232g(b)(1) and (b)(2)(A); 34 CFR § 99.30.

• To appropriate parties in connection with financial aid to a student;
• To organizations conducting certain studies for the school;
• To accrediting organizations;
• To individuals who have obtained court orders or subpoenas;
• To persons who need to know in cases of health and safety emergencies; and
• To state and local authorities, within a juvenile justice system, pursuant to specific state law.

School district staff members with access to student records must be identified by title and each student's file must include a record of access, on which all school staff members must sign whenever they consult that student's file. Staff that provide services within the area of a specific record so not have to sign it out each time they use the record. However if a school nurse accesses psychological records, she must sign and a psychologist must do the same when accessing health records. Schools must notify parents and eligible students annually of their rights. The actual means of notification (special letter, inclusion in a PTA bulletin, student handbook, or newspaper article) is left to the discretion of each school.

IDEA requires the school to maintain a record of all parties who obtain access to a child's

Directory Information:

Student name Address Telephone listing Electronic mail address Photograph Date and place of birth Major field of study Enrollment status (e.g., under- graduate or graduate; full-time or part-time) Participation in officially recognized activities and sports Weight and Height of members of the athletic teams Dates of attendance Degrees and awards received Previous educational agency or institution attended 34CFR §§ 99.31(a)(11); 99.

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Legal Considerations

educational records collected, maintained, or used under Part B of IDEA (with the exception of parents and authorized employees of the agency). This record should include the name of the person who accessed the records, the date, and the purpose for which the person was authorized to use the records (Section 300.563).

Colorado law specifically defines the content of a school request for written consent for the school district to release personally identifiable information concerning that parent's or legal guardian's child in education records other than directory information. The notice must include the specific records to be released, the reasons for the release, the identity of the person to whom the information will be released, the manner in which the release will be made (such as verbal, fax), and the parent’s right to review or receive a copy of the records to be released.^22 School nursing staff should maintain a log identifying those aside from regular health office staff, to whom access to the records has been given, when access occurred, and the specific records to which access was given.

(^22) CRS §22-1-123(6).

Transferring Records FERPA permits schools to transfer any and all education records, including disciplinary records, on a student who is transferring to another school.^23 School-generated health reports and assessments are routinely transferred along with the student's general records when a student transfers to a different school or district. The parent’s notification that a child is transferring is considered permission to transfer the child’s records to the new school.

Pertinent medical information that relates to the ability of a

school district to serve the

student or to the protection,

safety or welfare of others

should be summarized by

school personnel and placed

in an appropriate document

such as a 504 plan, an IEP, a behavior plan, or a health care plan. There is no regulation that specifically addresses transferring health records outside a school district about a student from an outside health provider, but districts should be aware of potential problems if they are shared without parent

(^23) No Child Left Behind Act of 2001, § allows schools to transfer disciplinary records, with respect to a suspension or expulsion, by local educational agencies to any private or public elementary school or secondary school for any student who is enrolled or seeks, intends, or is instructed to enroll, on a full- or part-time basis, in the school."

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Documents and the Role of the School Nurse

A great deal of a school nurse’s time is spent around documents: nurse’s notes; immunization records; an alphabet soup of plans; medication records; third- party billing; case management notes; referral notes; prescription orders, etc. Accurate, timely documentation of nurse-student interactions promotes high quality student health services, advances the efficiency and effectiveness of the school and district health program, and creates a legal record. Legal and ethical considerations require school nurses to document care and keep personal information confidential and secure.

The following section poses some frequently asked questions.

What Records Should I Create? Standard nursing practice includes the following components: assessment, planning, implementation, and evaluation. 25

• Assessing a child’s health requires collecting information from a variety of sources, such as the student, families, health care providers, school staff, and out-of- school organizations.
• Planning requires identification of action steps and interventions to promote, maintain, or restore health,

(^25) Minnesota Department of Health. (11/96). Minnesota School Health Guide. Section Two: Direct Services To Students. Chapter 6: Nursing Practice In The School Setting. http://www.health.state.mn.us/divs/fh/mch/CA REweb/schoolhealth/chapter6.html.

prevent illness, and/or provide rehabilitation for the individual student or a given population.

• Implementing the plan requires execution of the plan of care in a safe and appropriate manner.
• Evaluation is the systematic and ongoing appraisal of the effectiveness of the interventions as they relate to the outcomes and can result in identification of a need to reassess and revise health care plans. Each component requires collecting information and compiling that information into some sort of document. Standards of practice require the nurse to document each step in each component.

Colorado state law is not prescriptive as to what a health record must contain, with the exception of an immunization record, and vision and hearing screening results. (For example, there is no Colorado law requiring an incident report to be written after a serious student injury.^26 ) Appropriate

documents for an active student health record could include, but are not limited to: 27

(^26) US Centers for Disease Control and Prevention. State Level School Health Policies and Practices SHPSS Study Item 3. http://www.cdc.gov/nccdphp/dash/shpps/report _cards/pdf/colorado.pdf. 27 New Jersey Department of Education, Office of Educational Support Services (1997), School Health Services Guidelines 97 Topic

Student health information concerns two types of records: an active student health record and a cumulative health record. z The former is an active record for a child currently in a particular school. It could also be a file, containing multiple records, such as a health record, an IEP, a Health Plan, etc. z The latter Cumulative Health Record (CHR) is a compilation of the child’s total health experience while in one school: the CHR typically follows the child from school to school.

The rules about confidentiality and disclosure apply to both types of records.

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Documents and the Role of the School Nurse

• nurse's notes on students evaluated in the health office
• medication orders and records of administration;
• directives for limitation of physical activity;
• reports of physical examinations;
• reports of referrals;
• copies of health summaries for IEP Team referrals;
• health component of IEP;
• 504 Accommodation plan;
• emergency health plan;
• transportation plan;
• other forms as directed by district policy;
• student's health history;
• annual record of health screenings;
• documentation of referrals to outside medical and social sources;
• sensitive services;
• exclusions for communicable diseases;
• accident/incident reports of serious injuries;
• notifications to parents/guardians of immunization requirements, immunization records, including notation of granted provisional admission for medical or religious exemptions; and,
• record of transfers in or out of the file.

7D: Student Health Records. pp. 104- http://www.state.nj.us/njded/parents/shg.pdf.

What About My Personal Notes? Under federal law, a school nurse’s personal notes or calendar log would be considered a protected educational record, only as long as the school nurse kept them in her sole possession and did not share the actual notes.^28 Current federal regulations define the “sole possession” exception: as records that are kept in the sole possession of the maker, are used only as a personal memory aid, and are not accessible or revealed to any other person except a temporary substitute for the maker of the record. Examples of this type of record would include written (handwritten, and possibly electronic) notes that are typically thrown away once the writer’s memory was jogged, such as a calendar note to check on a referral, or a “post-it” or notes about a transient situation that does not impact academic achievement or safety that because of its sensitivity could cause harm or embarrassment

to the student in the future. A personal calendar note would be a personal (not protected) document; a formal log or sign in sheet would be a protected document. While these documents do not have to be made available to parents, they

(^28) 20 USC 1232g(4)(B).

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Documents and the Role of the School Nurse

• Update all records, including progress notes, IEPs, IHPs at least annually and when changes occur.
• Use nursing classification language.
• Be consistent over time with regard to frequency of documentation, based on district policy, nursing protocols and standards, and as the acuteness of the student’s health status demands.
• Record the student’s (or parent’s) own words.
• Document only objective data, relevant to the student’s care-- not personal judgements and nurse opinions.
• Do not reference district problems, such as staff shortages.
• Avoid terms suggestive of error, such as “accidentally” or “by mistake.”
• Don’t erase or use “white out.” Draw a line through the error, initial the line, and then write the correct entry.
• Note an entry in the wrong student’s file, by a line through the incorrect material, your initials, and the notation: “Entry made in error.”
• Avoid late entries; when they are absolutely necessary, indicate late entries with a notation “Late entry.”
• Detail any variation from standard protocols and any unusual student circumstances of situations. - Document in detail notifications regarding changes in a student’s health status or any unusual findings. - Document content of any telephone consultations and direction to assistive personnel - Include any prescriber orders and referral orders in health record. - Document medications given, stating when the medication was started and ended, at the end of the year, at the end of a course of medication, or when the dose changes, i.e. 1/5/02 – “Ritalin 10 mg daily. “ 5/20/02 – “Ritalin 10 mg daily stopped per MD order.” OR “Ritalin 10 mg daily from 8/15/2001 to 1/10/02; Ritalin 20 mg daily from 1/11/ to 5/12/02.” Once this information has been recorded, prescriber orders may be discarded.^29 - Document the name and title of anyone to whom access to a child’s health record was given. 30

It is critical that the documentation display accurate descriptions of events, conditions, and actions

(^29) Harrigan,J.F., (2002). Overview of school health services publication. National Association of School Nurses. 30 Student Health Services and Records (JLC) revised, the Colorado Association of School Boards (CASBE) After consultations with the Colorado School Health Advisory Board and the State School Nurse Consultant; Schwab, NC, Panettieri, MJ & Bergren, MD (1998). Guidelines for School Nursing Documentation: Standards, Issues and Model s, 2nd Edition; National Association of School Nurses.

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Documents and the Role of the School Nurse

taken to minimize the danger that a student may suffer from misuse of a record in the future and to maximize the protection of the nurse and the district if a record is needed later to demonstrate that appropriate procedures were followed. Descriptions of student behavior and condition, backed up by whatever objective information may be available (such as vital signs, description of physical injury, etc.), comprise one of the most important documents in dealing with situations that may be controversial.^31

What About Electronic Records? Faxes, computers, hand held computers, and the Internet have revolutionized record keeping and sharing of information, but the same rules of confidentiality and security apply to computerized health records as hard copy. The school must assure protection of computerized health information from a list of potential problems, including: computer hacking or unauthorized access (intentional attack), natural disaster (including power surges); human error, viruses, computer crashes, inadvertent release (such as protecting an open computer file from being seen), and insecure transmission over the internet.

• Computers crash, often when you least expect it. Electronic records must have backup

(^31) New Jersey SN Manual.

systems (tape, floppy, hard drive, or network drive) that are used scrupulously, consistently, and often. Staff using computers must have basic computer skills, such as knowledge about the necessity of frequent updating. The electrical hardware serving the computer should be sufficient to protect against power surges, electrical storms, use of other equipment, etc.

• Shared electronic files must have controlled levels of access. Password protection in various levels helps to prevent unauthorized access to sensitive material either for viewing or amending. For example a health aide may have access to one level of a health record, but not files deemed to be “restricted” The school nurse will be able to access all records. “Read only” capacity protects earlier material from being deleted either erroneously or maliciously_._
• To protect confidentiality, computer screens should be shielded from the casual visitor.^32

Some Ways to Promote Secure Maintenance of Automated Student Records

(^32 32) Schwab, NC, Panettieri, MJ & Bergren. National Association of School Nurses.10- CONFIDENTIALITY FAQs.doc – 6.

Some people use Social Security numbers as identifiers, other places have other ways of personally identifying people because they don’t want to use SS numbers. Before using a SS number on a record, you should make sure a) you don’t have a policy forbidding it and b) You have a good reason for using it.

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Documents and the Role of the School Nurse

What about keeping active health records? Health records should be kept in secured locations, separate from other student records, preferably in the school health office.^34 Written information should be labeled “confidential.” Electronic records should be saved on secure locations, such as password-protected files; and floppy discs and zip drives should also be kept in secured locations.

How do I protect confidentiality? The basic rule under FERPA and Colorado law is that medical diagnosis and other detailed health information should not be shared without informed consent from the student or the student’s parents except as permitted by law.

• The school nurse has a legal and ethical responsibility to disclose confidential information about a student when: o child abuse is suspected;^35 o there is an indication that the student may be suicidal or may be contemplating self- injury; or,

o there is the potential for

the student to injure another. 36

• The school nurse may share

health related information

(^34) Colorado Department of Education. (date) Special Care for Health Records. 35 36 §19-3-304, CRS. §24-72-204(3)(d)(V)(e)(1), CRS.

that will further a student’s

academic achievement

and/or maintain a safe and

orderly teaching

environment only with

school staff that have a

specific and legitimate

educational interest in the

information. 37 Making this

decision requires the

school nurse to exercise

professional judgment and

knowledge. 38

• It is not appropriate to post student names to a “Health Alert List” that is disseminated to all school staff. Not all staff members provide

services to all students and, therefore, not all staff needs to know the information on every student. Instead, a process should be implemented to identify individuals that have a legitimate educational interest and need to know the information in order for a student to functional optimally in the school setting.

The Colorado Department of Education recommends some basic rules, in addition to

(^37) Memorandum, CDE Commissioner of Education, May 2002 Confidentiality of School Health Records, http://www.cde.state.co.us/cdesped/download/ pdf/nur-Confidentiality.pdf. 38 NASSNC Position Statement National Association of State School Nurse Consultants. http://207.28.33.2/swp/tadkins/nassnc/NASSN C_confid.html#CONFIDENTIALITY

Personnel who have a legitimate NEED to KNOW – those employees, contract personnel or volunteers of an agency who provide direct services to the student or school officials with a legitimate educational interest as defined in the school records policy

Source: Schwab, N.C. & Gelfman, M.H.B. (2001) Legal issues in school health services: A resource for school administrators, school attorneys, school nurses. P. 307. Sunrise River Press, North Branch, MN.

DOCUMENTATION, RECORDKEEPING, and CONFIDENTIALITY

Documents and the Role of the School Nurse

Colorado law and FERPA, to assure privacy:

• establish policies and procedures that specifically address the handling of school health records;
• keep health records separate from other academic records;
• inform students and families about how student health information will be handled;
• provide training to all employees about confidentiality issues and the importance of protecting information;
• when releasing data, provide only the minimum details necessary to benefit the student’s education, health and/or safety; and
• assure security of records by assigning a trained individual to be accountable for health information security. 39

What about sensitive issues? The rules about maintaining confidentiality are stricter in health care settings than in schools with regard to certain sensitive health information, such as HIV status, mental health issues, pregnancy, abortion, and sexually transmitted diseases. In health care settings, medical information of this nature may not be released without the patient’s consent. These rules, however, do not apply in the school setting unless there are

(^39) Colorado Department of Education (2002). Confidentiality of school health records. http://www.cde.state.co.us/cdesped/download/ pdf/nur-Confidentiality.pdf

specific school district policies that address those issues. Ideally, when situations involving sensitive issues arise in schools, decisions about the sharing of information should be decided on a case-by-case basis, with consideration for the specific situation, the age and level of maturity of the student, and the student’s level of competency to manage the situation. School staff should always encourage a student to self-disclose to parents or guardians and may be instrumental in helping them do so.

A concern may arise if parents ask to see information in their child’s health record when that

record might contain information about sensitive issues that the student does not want the parent to see. The school nurse must make sure that, if documentation of such information is contained in the student’s record, the file can be compartmentalized in such a way that access to information about sensitive services can be protected from parental access until the student authorizes disclosure. (The advantages of electronic files for this type of information “layering” are obvious.)

FERPA and accompanying regulations define a “parent” as including both natural parents, custodial and non-custodial unless the school “has been