• Medications - Frequently Asked Questions

    Communication
    Can parents make changes in their child’s medication orders written by their provider?Changes in medication dosages must be ordered by the provider. A parent/guardian cannot direct licensed health professionals to administer medications to their child that are not consistent with the provider’s order. Provider orders instructing schools to consult with a parent/guardian for a dosage, when to give a medication, etc., are not acceptable orders unless the orders only allow the parent to provide proposed adjustments or dosages and require the health care professional to make the ultimate decision after exercising his/her professional judgment.

    Is parent consent needed in order for a Private Health Care Provider to clarify and order they have provided to the school? Parent/guardian consent to speak with the private provider is not required in order for the health care provider to clarify orders per the Health Insurance and Accountability and Portability Act (HIPAA):

    Medications - Frequently Asked Questions

    Communication
    Can parents make changes in their child’s medication orders written by their provider?Changes in medication dosages must be ordered by the provider. A parent/guardian cannot direct licensed health professionals to administer medications to their child that are not consistent with the provider’s order. Provider orders instructing schools to consult with a parent/guardian for a dosage, when to give a medication, etc., are not acceptable orders unless the orders only allow the parent to provide proposed adjustments or dosages and require the health care professional to make the ultimate decision after exercising his/her professional judgment.

    Is parent consent needed in order for a Private Health Care Provider to clarify and order they have provided to the school? Parent/guardian consent to speak with the private provider is not required in order for the health care provider to clarify orders per the Health Insurance and Accountability and Portability Act (HIPAA):

    “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. See page 6 of the Application of FERPA and HIPAA to Student Health Records - Joint Guidance from US Dept of Health and Human Services & US Department of Education - November 2008  

    Disposal of Medications
    How should medications be disposed?   Schools should inform the parent/guardian of their responsibility to pick up unused medication, ideally in writing. Such communication should include a deadline date for pick up including how parents/guardians who cannot meet the deadline date can make alternate arrangements, and that any medication not picked up by the deadline, or alternate date if arranged by the parent/guardian, will be disposed of. Medication is no longer to be flushed down a drain or toilet as a means of disposal.
    The following information is further outlined on page 45 of the NYS Department of Environmental Conservation recommendations.Guidelines for Medication Management in Schools -Revised 2017 (PDF) 


    Does the Environmental Protection Agency (EPA) consider the epinephrine salts in epinephrine auto-injectors to be hazardous waste? No, the New York State Department of Environmental Conservation (DEC) concurs with the USEPA Guidance RO# 14778 which concludes that the P042 listing does not include epinephrine salts. Virtually all pharmaceutical uses of epinephrine are epinephrine salts, and are not subject to RCRA C regulation as a hazardous waste. Therefore epinephrine auto injectors should be disposed of in the same manner as other sharps.

    Documentation
    What should be documented in the student’s cumulative record? Pursuant to Rules of the Board of Regents, Part 29 § 29.2(3), licensed health professionals must maintain a record for each patient which accurately reflects the evaluation and treatment of the patient. Additionally unlicensed personnel assisting Supervised or Independent Students to take their own medication should document the medication was taken by the student.

    What is the recommended procedure for record keeping? Schools should retain the written order from the prescriber and the written parent/guardian consent, document pertinent information about medication, and other vital signs, blood glucose etc. related to the administration in the cumulative health record, maintain an individual daily medication administration record (MAR) for each student administered medication, or self-administering medication in the health office and periodically and as needed evaluate and summarize student response to medication, including assessing for effectiveness and side effects.

    What information should be included in the medication administration record? The student name and date of birth;medication name, dosage, route, and parameters;the date and time administered;the signature and title of the health professional administering;parameters required for administration (e.g.. vital signs, carb count, blood glucose, etc.); and missed doses or student refusal.

    Emergency Building Procedures
    What items are recommended in the Emergency Building Procedures to be included in an emergency pack? Supplies for basic first aid, including supplies for infection control; a list of all students with significant medical conditions and medical orders for prescription medication, including emergency contact numbers;a stock epinephrine auto-injector with non-patient specific orders (if applicable); a glucose source-such as glucose gel, juice boxes or honey sticks; drinking water; and cell phone for communication with provider’s, parents/guardians, or emergency services. A building emergency plan should also address means for use of an opioid antagonist (naloxone) or epinephrine auto-injector included in district emergency response procedures, which in the public schools includes an Automated External Defibrillator (AED).

    Field Trips and Other School Sponsored Events
    How should medication be prepared for Field Trips and Other School Sponsored Events? When medications are to be given off school grounds or after school hours, the medications should remain in the original, properly labeled container until utilized by the student. See Clarification of Medication Storage in Schools Memo- http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/fieldtrips.pdf

    Who can administer medications to Nurse Dependent Students on a field trip? Nurse Dependent Students will need a licensed health professional to attend the field trip in order to administer their medication to them. Parents/guardians may choose to accompany their child on the trip to administer their child’s medication; however parents/guardians of such students cannot be required to attend a field trip. A parent/guardian may choose to appoint a parent designee who is a friend or family member to act in their place and administer medication to their child at a single school event or field trip. Appointment of a parent designee is the choice of the parent/guardian, and school personnel may not require a parent/guardian to appoint one.See http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/fieldtrips.pdf Districts should be knowledgeable about and ensure compliance with applicable Federal laws including, but not necessarily limited to, the Americans with Disabilities Act (ADA) and the Individuals with Disabilities Education Act (IDEA). These laws require students’ accessibility to all school events, including field trips. If a licensed health professional is not available to attend the trip to meet the health needs of a student or students, and the parent(s)/guardian(s) choose not to attend or appoint a designee, then the field trip is to be canceled rather than exclude a student due to their health needs consistent with Federal Laws. 

    Who can assist a Supervised Student with medication on a field trip? Oversight of medication self-administration by Supervised Students may be delegated to trained unlicensed school personnel. Such personnel must be appropriately instructed by a licensed school professional (RN, NP, PA, or physician) to assist a self-directed student. 

    May Independent Students carry and self-administer their own medications on field trips? Students with provider orders and attestation, and written parent/guardian consent may carry and self- administer their own rescue medications for respiratory conditions, epinephrine auto-injector, or insulin, glucagon, and related diabetes supplies at school sponsored events. Independent Students with other health conditions warranting timely administration of their medications should also be permitted to self-carry and self-administer their medication to prevent negative health outcomes.

    Intravenous Medications
    May school administer medications intravenously to students? Yes, but schools should only administer medications, including intravenous (IV) medications, which must be administered during school and cannot be administered at another time of day.Only students who have indwelling central lines such as a port, Groshong, Hickman or other similar catheters, and peripherally inserted central catheter (PICC) lines may have IV medications administered at school.The student must have had the first dose of the medication administered at a medical facility, provider’s office, or other appropriate location. This is done to insure the patency of the central line, pump functioning if one is used, and that the student can tolerate the medication infusion without immediate side effects.

    What are the considerations for safe administration of intravenous medication at school? 1) The school nurse (RN) must be trained in the administration of the medication, use of the infusion pump if utilized, and care of the line and insertion site. 2) Training must be arranged by the ordering health care provider and can occur in the provider’s office, local hospital, by a visiting nurse, or by the infusion company. 3) Provider orders will need to include information on the type, care and maintenance of intravenous line and insertion site, and steps to take if intravenous access is lost, inaccessible, or the pump malfunctions. The medication order should include dosing, side effects and other signs and symptoms to observe for that will require notifying the provider. Information on the name of the infusion supply company along with their contact information should also be included on the orders. 4) Parents/guardians will need to provide the school with the student’s diagnosis, the medication, and all necessary supplies along with the provider orders and written consent for the school to contact the provider as necessary.

    Legislative Background
    May a school nurse follow a medication order written by a provider from out of state? The provider writing the medication order must be duly licensed to practice in New York State or qualifies for an exemption under Article 131 § 6526 (see http://www.op.nysed.gov/prof/med/article131.htm

    This link to Article 131 - Article 131 Section 6526 - lists out-of-state medical providers that are permitted to practice in the state without a NYS license, and therefore are able to perform a health examination and produce a health certificate to be submitted to NYS schools. Education Law 131 section 6526 permits 9 exemptions to the requirement for NYS licensure to practice medicine in NYS. The two most applicable to school health include:

      1. A physician who is licensed in a bordering state and who resides near a border of New York State, provided their practice is limited in this state to the vicinity of that border and the physician does not maintain an office or place to meet patients or receive calls within New York State. The Education Department generally interprets that the physician's office should be located within approximately 50 miles of the state border. The student's location of residence is not a factor.
      2. Any commissioned medical officer who is serving in the United States armed forces or public health service or any physician who is employed in the United States Veterans Administration, provided such practice is limited to such service or employment.

    What non-patient specific orders may the school nurse (RN) follow? Education Law Articles 131 and 139 permit a physician, and a nurse practitioner to write non-patient specific orders for an RN to follow for the following only: administrating immunizations, the emergency treatment of anaphylaxis, administering purified protein derivative (PPD) and HIV tests, administering tests to determine the presence of the hepatitis C virus and the emergency treatment of opioid related overdose or suspected opioid related overdose.

    Medication Administration
    Who should administer medications in school? Medications must be administered by an appropriately licensed health professional: physicians, nurse practitioners (NP), physician assistants (PA), registered professional nurses (RN), and licensed practical nurses (LPN) under the direction of an RN or the other health professionals listed above. Supervised and Independent Students may be assisted by trained unlicensed personnel to take their own medications. Documentation of the medication dose must be recorded in the individual student’s cumulative health record (CHR).

    Can a certified Athletic Trainer (ATc) administer medications? No. The only professions permitted to administer medications to another person in NYS include all authorized prescribers and registered professional nurses, licensed practical nurses, respiratory therapists and respiratory therapy technicians. Additionally schools must have patient specific orders and written parent/guardian consent for those licensed professionals to administer to the student, or for the student to self-administer.

    If a student’s medication is expired, can the school nurse administer that medication? No, medications that have expired should not be administered by a licensed health professional, per Rules of the Board of Regents Part 29.14 (2)(i): http://www.op.nysed.gov/title8/part29.htm  The parent/guardian should be notified of the need to bring in new medication to replace the expired one at least one month in advance of expiration. An easy method to track expiration dates is to note it at the top of the medication administration record (MAR). Note:Pharmacists in NYS are not required to place expiration dates on labels, with a few exceptions such as antibiotic suspensions. Therefore, manufacturer expiration dates may be relied upon per the NYS Board of Pharmacy (The date on the pharmacy bottle is one year from the date the prescription was filled.)

    Where should medications be administered?  Students will generally need to go to the health office for an appropriate licensed health professional to administer the medication to the student, or to take their own medication. Education Law Article 19 §916, §916-a, §916-b requires that schools permit students who have both written provider orders, provider attestation and parent guardian consent to carry and self-administer: inhaled rescue medications; epinephrine auto-injector, and insulin, glucagon and other supplies for diabetes management. These students must not be made to come to the health office for their medications. Schools should also extend to Independent Students the right to self-carry and self-administer medications that require rapid administration to prevent negative health outcomes

    When should medications be administered? All medications should be administered as close to the prescribed time as possible. Given student schedules and students’ compliance with coming to the health office in a timely fashion, medications accepted for school administration generally may be given up to one hour before and no later than one hour after the prescribed time, which is considered best practice.

    If a tablet does not come in the dose the provider ordered, may they be split using a pill cutter?On occasion a tablet does not come in the dose the provider ordered. If the medication tablets are scored they may be split with a pill cutter.  Using a pill cutter is necessary to ensure the pill splits evenly and does not crumble. Such scored tablets may be cut by a nurse prior to administration.  Alternatively, the parent/guardian may request they are cut by the pharmacist. Tablets that are not scored should not be cut since they will not split evenly and the dosage will be unknown. ( NYSED Guidelines for Medication Management in Schools , Last Updated September 2015 , Page# 16 )  
     
     

    What happens if a parent/guardian withdraws their consent in writing for the school to administer a particular medication? The school will need to comply with the parent’s/guardian’s instructions and contact the provider to inform him/her and obtain a written order to discontinue the administration of the medication at school. Parent/guardians making verbal requests to withdraw consent should be instructed to do so in writing. School protocols may permit acceptance of verbal parent/guardian requests if followed up by written request within a specific time frame.

    If a parent/guardian fails to provide an emergency medication for a student with a diagnosis that requires such medication, should the student be excluded? The student should not be excluded. Written communication to parents/guardians should note that in the absence of the medication, emergency medical services (EMS) would be called to transport to local emergency room.   The district medical director or school nurse should communicate this information to the student’s provider if orders for the medication had been provided to the school previously. Schools should be cognizant of financial constraints a family may face in obtaining the medication, and assist by providing information on obtaining insurance or reduced cost medications from manufacturers if available: https://www.staterxplans.us/new-york.html . New York State has a health insurance plan for kids, called Child Health Plus. Depending on family income, children may be eligible to join either Children's Medicaid or Child Health Plus. Both Children's Medicaid and Child Health Plus are available through dozens of providers throughout the state with little or no out of pocket expense.

    If the provider confirms that the student must have such medication available at school, the school should work with the parent/guardian to resolve the need for the emergency medication to ensure the safety of their child at school. If all attempts to have the parent/guardian provide the medication fail, the school will need to consider notifying Child Protective Services (CPS).

    Medication Errors
    How is a medication error defined? A medication error includes any failure to administer medication as prescribed for a particular student including failure to administer the prescribed medication to the correct student, at the correct time, at the correct dose, or by the correct route. 

    What steps should be followed if a medication error occurs? The following steps should be taken for medication errors: Notify the licensed prescriber as soon as possible, particularly if wrong dose administered;notify supervisor and/or school administrator, and school medical director;notify the parent/guardian; and complete a written report of the medication error detailing student's name, specific statement of the medication error, results of the school nurse assessment, who was notified, and what remedial action was taken. There is a sample Medication Incident Reporting Form on the NYSCSH website.

    Non-FDA Sanctioned Medication Requests
    Must a school honor a request to apply Essential Oils during the school day? Requests or orders for use of non-FDA sanctioned medicines including but not limited to, herbal remedies, dietary supplements, naturopathic or holistic medicines, and natural products do not need to be honored by a school district or school nurse. Schools should explain to the provider and the parent/guardian that such medications should be administered outside of school and document in the student’s cumulative health record.

    Over the Counter Medications (OTC)
    Do OTC medications require both parent and provider written permission to administer at school? Yes, all medications both prescription and non-prescription require provider written permission – with the exception of the 2 listed below.

    What 2 non-prescription medication orders do not require a licensed medical provider order? Sunscreen pursuant to Article 19 §907 of Education Law may be used with parent permission and alcohol based hand sanitizers may be used with an order from the school medical director.

    What happens if the provider order is for one brand of either prescription or non-prescription medication, but the parent/guardian brings in a different brand, is it acceptable for the nurse to administer it? If both brands are identical dosages (Advil and Motrin - both ibuprofen or Epi-Pen and Auvi Q both epinephrine) the school can accept and administer the medication.

    Opioid Antagonists
    What 3 options exist for schools wanting to incorporate Opioid Antagonists in their school policy? Option #1- Becoming a NYSDOH Registered Opioid Overdose Prevention Program. OPTION #2-Issuing a Non-patient Specific Order. OPTION #3 - Permitting Volunteers to be trained by a NYSDOH Registered Overdose Prevention Program. Please Note: Detailed instructions on the maintenance, inventory & storage, documentation, and notification requirements of a registered opioid overdose prevention program are available on the NYSCSH Opioid resource page.

    Prescription Medications
    May the nurse re-label a medication bottle if there is a change in the dose, time or frequency of the medication requested in writing by the provider and parent/guardian?  When the dose, time, or frequency of a medication is changed by a written provider order along with written parent/guardian consent, and the pharmacy bottle label does not reflect the new order, the nurse may label the bottle with the date, new dose, and/or frequency until a new pharmacy labeled prescription bottle is received. This is only permissible if the medication in the existing bottle can be used for the new order.

    What extra precautions should be taken upon receipt of controlled substances? A sample form may be found on the NYSCSH website by clicking here.  For certain medications, particularly controlled substances, standards of best practice include counting the medication upon receipt. Counting should also occur at regular intervals (e.g.. daily or once/week) throughout the school year. Ideally a count of a controlled substance should be witnessed by another nurse, principal, or staff member designated by the principal.

    If a tablet does not come in the dose the provider ordered, may the school nurse split the pill? If the medication tablets are scored they may be split with a pill cutter. Using a pill cutter is necessary to ensure the pill splits evenly and does not crumble. Such scored tablets may be cut by a nurse prior to administration. Alternatively, the parent/guardian may request they are cut by the pharmacist. Tablets that are not scored should not be cut since they will not split evenly and the dosage will be unknown.

    Record Retention
    How long should student medication orders and parent/guardian consents be kept?  These records should be kept for one year after the end of the school year, as long as the information is transcribed into CHR on either an MAR or narrative. Medication orders and parent/guardian consents not transcribed, along with the MAR and narrative need to be kept in the cumulative health record by the school until the student reaches age 27. 

    Specific Diagnosis or Medical Considerations
    What new specific diagnoses or medical conditions have been included in the new Medication Guidelines? Diabetes Management,Blood glucose monitoring,monitoring of urine ketones or glucose, insulin administration, continuous glucose monitoring (CGM), Glucagon administration, Diastat, Epinephrine and Opioid Overdose Prevention Management have all been detailed on pages 28-35.

    Who may administer Diastat to a student? During a seizure, a student would be considered Nurse Dependent necessitating the medication be administered by a school nurse (RN), NP, PA, or physician due to the need for assessment to determine whether or not it is to be administered. However, in cases where a student has a consistent, predictable seizure pattern, an LPN under the direction of an RN may administer the medication. The LPN will need a detailed emergency action plan specifying the signs and symptoms that will warrant administering. If the RN is not on site with the LPN, the LPN must be able to contact the RN as needed, and the RN must be able to respond on site within 15 minutes.

    Staffing
    What does “under the direction of” mean for LPNs administering medications in the school setting?  Under the direction means the directing practitioner must provide an appropriate degree of direction to the LPN, which is determined by the care needs of the students, and the skill and ability of the LPN. The directing practitioner does not necessarily have to be on premises to direct an LPN where the directing practitioner is available to direct the LPN by telephone and can personally intervene within 15 minutes to ensure timely and appropriate care. (see #8 under RN and LPN, http://www.op.nysed.gov/prof/nurse/nursepracticefaq.htm)

    Stock Medication
    May schools choose to purchase and stock over the counter (OTC) medications for use by students and staff? This practice is not recommended, but it is not prohibited by law.   Schools choosing to stock medications must have written patient specific orders from the student’s provider and written parent/guardian consent permitting administration of stock medication. Stock medications for staff use, should be kept in a location other than the health office for staff to obtain if the school employs licensed health professionals. This is strongly recommended to eliminate any liability for the licensed health professional.

    May schools stock albuterol for use by students? Yes, if there is a patient specific order from their provider and written parent/guardian consent for albuterol that also authorizes the use of the school’s stock albuterol.

    May schools stock Potassium Iodide? School building administrators located in the ten mile emergency planning zones of nuclear power plants have been asked to participate in the Potassium Iodide (KI) Program. More information on the KI Program is available at: http://www.health.ny.gov/environmental/radiological/potassium_iodide/fact_sheet.htm

    Storage
    How should Medications be stored? Schools are not required to, but are strongly encouraged to utilize best practice double lock systems similar to those required in other health settings. Such systems include: being properly stored and secured within a health office cabinet, drawer, or refrigerator designated for medications only with a lock for the cabinet, drawer, and/or refrigerator as well as a lock to the outside health office door; should be secured to the wall or floor, and should not have breakable glass doors; being stored in a refrigerator used solely for that purpose to avoid cross contamination. The health office should always be locked when health services personnel or staff members trained to assist students are not present.

    Student Functional Categories
    What are the three functional categories of students when it comes to medication administration? They are -Nurse Dependent Students (formerly non-self-directed) -Supervised Students (formerly self-directed) -Independent Students (formerly self-administer and/or self-carry). Pages 8-10 of the medication guideline contain more information. A chart with the Levels of Assistance in Medication Delivery may be found here .

    What does Nurse Dependent mean? Students, who cannot self-administer their own medication and cannot be considered in need of supervision, are dependent on another person administering the medication to them. Nurse Dependent Students must have their medication administered to them by an appropriate licensed health professional.

    Who determines if a student can be considered Supervised? Students can be determined to need supervision either by the school nurse or the student's provider.  We have created a Sample Nursing Assessment for Determination of Supervised Students to assist the school nurse. Click here to view this form.

    Who determines if a student is Independent? The health care provider ordering the medication. The school nurse would not assess those student’s ability to be self directed or instruct them in self- administration It is recommend that they are instructed in how to safely carry on their person or store in a locker. On page 10 of the new guidelines we also include the need for an emergency care plan, and additional doses of medication in the health office for use as needed by the student.

    Students who require rescue medications for respiratory conditions, life-threatening allergies, or diabetes must be permitted to self-carry and self-administer their medications if they have what written permissions in place? A provider order and written parent/guardian consent for the student to self-carry and self-administer their medication pursuant to Article 19 Sections 916, 916-a, 916-b of Education Law must be in place. The provider order must also attest in writing that the provider has determined the student is able to self-administer their own medication effectively. Forms for this are on the website A-Z Resources, Medication subpage

    What about other medications which require timely administration?
    Independent Students with health conditions warranting rapid administration of their medications should also be permitted to self-carry and self-administer their medication to prevent negative health outcomes if they provide the same documentation as described above, and that any questions regarding such orders should warrant a telephone call by the school nurse or medical director to confirm the need for rapid administration warranting the student to carry the medication.

    Texting with Parent/Guardians about Medication (Text Messages for School Nurses: CAS Legal Mailbag Question of the Week – June, 2017 Answers from: SHIPMAN & GOODWIN Over 175 Attorneys Offices throughout Connecticut, New York & DC)

    Question: The typical public school nurse today most likely works with several students with severe and/or life threatening conditions that often require immediate attention. With the popularity and convenience of texting, many parents prefer to communicate via text regarding treatment for their child. For example, one mother of a second grade student with diabetes works during the school day and cannot take phone calls. She requests that the nurse text her with out-of-normal-range blood sugar levels of the student so that they may communicate about the student’s treatment. How is this practice affected by FERPA? Also, can any violation of FERPA be circumvented by the parent signing a waiver?

    Answer: As an initial matter, it would be prudent to first consult any board of education policies or regulations that may govern the use of text messages by employees for job-related purposes. Assuming no such board of education policies or regulations exist, aside from a true emergency when the school may need to use any means necessary to contact a parent, there are a number of reasons why the school nurse should not communicate with parents via text message about students’ medical needs and treatment.

    First, as you contemplate, the use of text messages for such a purpose could implicate the Family Educational Rights and Privacy Act (FERPA), which governs the confidentiality and disclosure of student education records and also provides parents the right to inspect such records. Under FERPA, an education record is defined as a record that directly relates to a student that is maintained by an educational agency (such as a school district) or a party acting for the agency. Text messages between a nurse and a parent about a student certainly would directly relate to that student, and although an unsettled question, one could argue that the nurse, who is a party acting for the agency, could be “maintaining” such text messages. Parents have the right to access their child’s education records under FERPA, and, therefore, a release from the parent would not be necessary to disclose information to the parent about the student. However, responding to a subsequent request by the parent to inspect all of the student’s education records related to the student’s health or treatment would be difficult if many of the records were contained on the nurse’s phone. The concern is then compounded by the possibility that the nurse may not retain the text messages, which might even be automatically deleted after a period of time.

    Regardless of the FERPA issues, however, the use of text messages for communication between the nurse and a parent regarding student health or treatment is ill advised. Communication between school nurses and parents about students’ health and treatment should be documented for a number of reasons, not the least of which is the ability to demonstrate that the school nurse acted appropriately or reasonably in a given situation and that he or she (and the district) properly implemented a student’s treatment protocol, Section 504 plan, or individualized health care plan. A text message thread between the nurse and parent could be inadequate for that purpose.

    Additionally, as noted above, there may be record retention problems with text messages. In addition to intentional or inadvertent deletion of text messages, phones die or may be lost or stolen; employees retire or resign, taking their phones with them; and employees may be uncooperative in providing access to their text messages. In short, retrieving and reviewing such text messages at a later date may be impossible. In addition, the school nurse likely would not want her phone and texts subject to a subpoena in a lawsuit or administrative proceeding initiated by a parent, which is always a possibility in our litigious society.

    Instead, a better solution for the nurse would be to use his or her school district email account to communicate with a parent who requests to communicate electronically rather by phone. Of course, such email communication should always be professional and with an appropriate level of formality. Emails create a clearer record, can easily be printed for a student’s file, and are much easier for the district to review and recover if needed. Moreover, if a parent is able to read and respond to a text message on his or her phone, he or she similarly should be able to read and respond to an email on his or her phone. If immediate communication is desired, the nurse can text the parent (or vice versa) with a notification that he or she has sent an email. In short, it is best for school nurses not to communicate about medical issues with a parent through text messages.

    Timing of Medication Orders
    When must a provider order be renewed? The order, which is valid for 12 months, should be renewed annually or when there is a change in the order. District policy should state whether new provider orders and parent/guardian consent is required at the start of the school year or when the order expires.

    Training
    If a school nurse is not familiar with certain medications or delivery methods, what should they do? She/he should inform school administration of the need for appropriate training in order to safely administer the medication. Schools must ensure they have the necessary training to meet the students’ needs, and are up to date in best practice. Therefore schools must seek out necessary training for staff and encourage and assist their licensed health professionals to regularly participate in professional development.  

    Who is responsible to train unlicensed personnel to assist Supervised/Independent students in taking their own medications? A sample form may be found on the NYSCSH website by clicking here. Training must be done by appropriately licensed health professionals and should be done in an organized manner and include how to assist the student; how to keep medications safe; how to document; the importance of confidentiality and should include a return demonstration. The training should be documented per district policy.If a student is independent but takes their medication in the health office, staff should be trained to hand them the bottle and review safe storage practices.

    May school nurses train unlicensed personnel to administer Epinephrine Auto-Injectors and Glucagon to students with orders? Yes, in accordance with Education Law Article 19 § 921-a, unlicensed personnel may be trained by an RN, NP, PA or physician to administer emergency epinephrine via auto-injector, or emergency glucagon to a student with a provider order. Such training must be done in accordance with specifications outlined in Commissioner’s Regulation 136.7

    Transporting Medication to School
    Who is responsible for transporting medications to school? The parent/guardian is responsible to have the medication delivered directly to the school in a properly labeled original container by an adult. In limited circumstances, a student who is not able to self-administer their medication may need to carry the medication on the bus in order to transport it to and from school for medical reasons or due to the family’s financial constraints. A written plan to ensure the safety of the student, as well as the safe transport of the medication should be developed in collaboration with the medical director or school nurse and the parent/guardian.

    Can an RN take a verbal order from a licensed provider? There is nothing in State regulation or statute that pertains specifically to school nurses in relation to verbal orders. As with any RN, school nurses may take a verbal order. We suggest the following procedure, but each medical director sets his/her own policy. The nurse should repeat the order to the provider for accuracy, have a second nurse verify by listening in (if possible), obtain the provider's signature on the written order within 48 hours

    Page updated 12/3/19

     

     

    “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. See page 6 of the Application of FERPA and HIPAA to Student Health Records - Joint Guidance from US Dept of Health and Human Services & US Department of Education - November 2008  

    Disposal of Medications
    How should medications be disposed?   Schools should inform the parent/guardian of their responsibility to pick up unused medication, ideally in writing. Such communication should include a deadline date for pick up including how parents/guardians who cannot meet the deadline date can make alternate arrangements, and that any medication not picked up by the deadline, or alternate date if arranged by the parent/guardian, will be disposed of. Medication is no longer to be flushed down a drain or toilet as a means of disposal.
    The following information is further outlined on page 45 of the NYS Department of Environmental Conservation recommendations.Guidelines for Medication Management in Schools -Revised 2017 (PDF) 


    Does the Environmental Protection Agency (EPA) consider the epinephrine salts in epinephrine auto-injectors to be hazardous waste? No, the New York State Department of Environmental Conservation (DEC) concurs with the USEPA Guidance RO# 14778 which concludes that the P042 listing does not include epinephrine salts. Virtually all pharmaceutical uses of epinephrine are epinephrine salts, and are not subject to RCRA C regulation as a hazardous waste. Therefore epinephrine auto injectors should be disposed of in the same manner as other sharps.

    Documentation
    What should be documented in the student’s cumulative record? Pursuant to Rules of the Board of Regents, Part 29 § 29.2(3), licensed health professionals must maintain a record for each patient which accurately reflects the evaluation and treatment of the patient. Additionally unlicensed personnel assisting Supervised or Independent Students to take their own medication should document the medication was taken by the student.

    What is the recommended procedure for record keeping? Schools shouldretain the written order from the prescriber and the written parent/guardian consent, document pertinent information about medication, and other vital signs, blood glucose etc. related to the administration in the cumulative health record, maintain an individual daily medication administration record (MAR) for each student administered medication, or self-administering medication in the health office and periodically and as needed evaluate and summarize student response to medication, including assessing for effectiveness and side effects.

    What information should be included in the medication administration record? The student name and date of birth;medication name, dosage, route, and parameters;the date and time administered;the signature and title of the health professional administering;parameters required for administration (e.g. vital signs, carb count, blood glucose, etc.); and missed doses or student refusal.

    Emergency Building Procedures
    What items are recommended in the Emergency Building Procedures to be included in an emergency pack? Supplies for basic first aid, including supplies for infection control; a list of all students with significant medical conditions and medical orders for prescription medication, including emergency contact numbers;a stock epinephrine auto-injector with non-patient specific orders (if applicable); a glucose source-such as glucose gel, juice boxes or honey sticks; drinking water; anda cell phone for communication with provider’s, parents/guardians, or emergency services. A building emergency plan should also address means for use of an opioid antagonist (naloxone) or epinephrine auto-injector included in district emergency response procedures, which in the public schools includes an Automated External Defibrillator (AED).

    Field Trips and Other School Sponsored Events
    How should medication be prepared for Field Trips and Other School Sponsored Events? When medications are to be given off school grounds or after school hours, the medications should remain in the original, properly labeled container until utilized by the student. See Clarification of Medication Storage in Schools Memo- http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/MedicationAdministration.pdf

    Who can administer medications to Nurse Dependent Students on a field trip? Nurse Dependent Students will need a licensed health professional to attend the field trip in order to administer their medication to them. Parents/guardians may choose to accompany their child on the trip to administer their child’s medication; however parents/guardians of such students cannot be required to attend a field trip. A parent/guardian may choose to appoint a parent designee who is a friend or family member to act in their place and administer medication to their child at a single school event or field trip. Appointment of a parent designee is the choice of the parent/guardian, and school personnel may not require a parent/guardian to appoint one.See http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/fieldtrips.pdf Districts should be knowledgeable about and ensure compliance with applicable Federal laws including, but not necessarily limited to, the Americans with Disabilities Act (ADA) and the Individuals with Disabilities Education Act (IDEA). These laws require students’ accessibility to all school events, including field trips. If a licensed health professional is not available to attend the trip to meet the health needs of a student or students, and the parent(s)/guardian(s) choose not to attend or appoint a designee, then the field trip is to be canceled rather than exclude a student due to their health needs consistent with Federal Laws. 

    Who can assist a Supervised Student with medication on a field trip? Oversight of medication self-administration by Supervised Students may be delegated to trained unlicensed school personnel. Such personnel must be appropriately instructed by a licensed school professional (RN, NP, PA, or physician) to assist a self-directed student. 

    May Independent Students carry and self-administer their own medications on field trips? Students with provider orders and attestation, and written parent/guardian consent may carry and self- administer their own rescue medications for respiratory conditions, epinephrine auto-injector, or insulin, glucagon, and related diabetes supplies at school sponsored events. Independent Students with other health conditions warranting timely administration of their medications should also be permitted to self-carry and self-administer their medication to prevent negative health outcomes.

    Intravenous Medications
    May school administer medications intravenously to students? Yes, butschools should only administer medications, including intravenous (IV) medications, which must be administered during school and cannot be administered at another time of day.Only students who have indwelling central lines such as a port, Groshong, Hickman or other similar catheters, and peripherally inserted central catheter (PICC) lines may have IV medications administered at school.The student must have had the first dose of the medication administered at a medical facility, provider’s office, or other appropriate location. This is done to insure the patency of the central line, pump functioning if one is used, and that the student can tolerate the medication infusion without immediate side effects.

    What are the considerations for safe administration of intravenous medication at school? 1) The school nurse (RN) must be trained in the administration of the medication, use of the infusion pump if utilized, and care of the line and insertion site. 2) Training must be arranged by the ordering health care provider and can occur in the provider’s office, local hospital, by a visiting nurse, or by the infusion company. 3) Provider orders will need to include information on the type, care and maintenance of intravenous line and insertion site, and steps to take if intravenous access is lost, inaccessible, or the pump malfunctions. The medication order should include dosing, side effects and other signs and symptoms to observe for that will require notifying the provider. Information on the name of the infusion supply company along with their contact information should also be included on the orders. 4) Parents/guardians will need to provide the school with the student’s diagnosis, the medication, and all necessary supplies along with the provider orders and written consent for the school to contact the provider as necessary.

    Legislative Background
    May a school nurse follow a medication order written by a provider from out of state? The provider writing the medication order must be duly licensed to practice in New York State or qualifies for an exemption under Article 131 § 6526 (see http://www.op.nysed.gov/prof/med/article131.htm

    This link to Article 131 - Article 131 Section 6526 - lists out-of-state medical providers that are permitted to practice in the state without a NYS license, and therefore are able to perform a health examination and produce a health certificate to be submitted to NYS schools. Education Law 131 section 6526 permits 9 exemptions to the requirement for NYS licensure to practice medicine in NYS. The two most applicable to school health include:

      1. A physician who is licensed in a bordering state and who resides near a border of New York State, provided their practice is limited in this state to the vicinity of that border and the physician does not maintain an office or place to meet patients or receive calls within New York State. The Education Department generally interprets that the physician's office should be located within approximately 50 miles of the state border. The student's location of residence is not a factor.
      2. Any commissioned medical officer who is serving in the United States armed forces or public health service or any physician who is employed in the United States Veterans Administration, provided such practice is limited to such service or employment.

    What non-patient specific orders may the school nurse (RN) follow? Education Law Articles 131 and 139 permit a physician, and a nurse practitioner to write non-patient specific orders for an RN to follow for the following only: administrating immunizations, the emergency treatment of anaphylaxis, administering purified protein derivative (PPD) and HIV tests, administering tests to determine the presence of the hepatitis C virus and the emergency treatment of opioid related overdose or suspected opioid related overdose.

    Medication Administration
    Who should administer medications in school? Medications must be administered by an appropriately licensed health professional: physicians, nurse practitioners (NP), physician assistants (PA), registered professional nurses (RN), and licensed practical nurses (LPN) under the direction of an RN or the other health professionals listed above. Supervised and Independent Students may be assisted by trained unlicensed personnel to take their own medications. Documentation of the medication dose must be recorded in the individual student’s cumulative health record (CHR).

    Can a certified Athletic Trainer (ATc) administer medications? No. The only professions permitted to administer medications to another person in NYS include all authorized prescribers and registered professional nurses, licensed practical nurses, respiratory therapists and respiratory therapy technicians. Additionally schools must have patient specific orders and written parent/guardian consent for those licensed professionals to administer to the student, or for the student to self-administer.

    If a student’s medication is expired, can the school nurse administer that medication? No, medications that have expired should not be administered by a licensed health professional, per Rules of the Board of Regents Part 29.14 (2)(i): http://www.op.nysed.gov/title8/part29.htm  The parent/guardian should be notified of the need to bring in new medication to replace the expired one at least one month in advance of expiration. An easy method to track expiration dates is to note it at the top of the medication administration record (MAR). Note:Pharmacists in NYS are not required to place expiration dates on labels, with a few exceptions such as antibiotic suspensions. Therefore, manufacturer expiration dates may be relied upon per the NYS Board of Pharmacy (The date on the pharmacy bottle is one year from the date the prescription was filled.)

    Where should medications be administered?  Students will generally need to go to the health office for an appropriate licensed health professional to administer the medication to the student, or to take their own medication. Education Law Article 19 §916, §916-a, §916-b requires that schools permit students who have both written provider orders, provider attestation and parent guardian consent to carry and self-administer: inhaled rescue medications; epinephrine auto-injector, and insulin, glucagon and other supplies for diabetes management. These students must not be made to come to the health office for their medications. Schools should also extend to Independent Students the right to self-carry and self-administer medications that require rapid administration to prevent negative health outcomes

    When should medications be administered? All medications should be administered as close to the prescribed time as possible. Given student schedules and students’ compliance with coming to the health office in a timely fashion, medications accepted for school administration generally may be given up to one hour before and no later than one hour after the prescribed time, which is considered best practice.

    If a tablet does not come in the dose the provider ordered, may they be split using a pill cutter? If the medication tablets are scored they may be split (with a pill cutter) by a nurse prior to administration. The parent/guardian may also request they are cut by the pharmacist. If the pharmacist is unwilling to cut the unscored tablets, we do not advise a licensed nurse do so. Contact the provider to explain the issue and that the school nurse cannot be liable for cutting unscored tablets and thus administering an unknown dosage. The provider then has two choices, have the medication cut and administered by the parent at home, or change the dosage or medication to one the school may administer. There is a document from Office of Professions on the subject which can be found on the A-Z Index, under “M” for Medication Resources @ Medication - Tablet Splitting - Policy Guidance from NYSED, Office of the Professions, NYS Board of Pharmacy (Jan 2000)

    What happens if a parent/guardian withdraws their consent in writing for the school to administer a particular medication? The school will need to comply with the parent’s/guardian’s instructions and contact the provider to inform him/her and obtain a written order to discontinue the administration of the medication at school. Parent/guardians making verbal requests to withdraw consent should be instructed to do so in writing. School protocols may permit acceptance of verbal parent/guardian requests if followed up by written request within a specific time frame.

    If a parent/guardian fails to provide an emergency medication for a student with a diagnosis that requires such medication, should the student be excluded? The student should not be excluded. Written communication to parents/guardians should note that in the absence of the medication, emergency medical services (EMS) would be called to transport to local emergency room.   The district medical director or school nurse should communicate this information to the student’s provider if orders for the medication had been provided to the school previously. Schools should be cognizant of financial constraints a family may face in obtaining the medication, and assist by providing information on obtaining insurance or reduced cost medications from manufacturers if available: https://www.staterxplans.us/new-york.html . New York State has a health insurance plan for kids, called Child Health Plus. Depending on family income, children may be eligible to join either Children's Medicaid or Child Health Plus. Both Children's Medicaid and Child Health Plus are available through dozens of providers throughout the state with little or no out of pocket expense.

    If the provider confirms that the student must have such medication available at school, the school should work with the parent/guardian to resolve the need for the emergency medication to ensure the safety of their child at school. If all attempts to have the parent/guardian provide the medication fail, the school will need to consider notifying Child Protective Services (CPS).

    Medication Errors
    How is a medication error defined? A medication error includes any failure to administer medication as prescribed for a particular student including failure to administer the prescribed medication to the correct student, at the correct time, at the correct dose, or by the correct route. 

    What steps should be followed if a medication error occurs? The following steps should be taken for medication errors: Notify the licensed prescriber as soon as possible, particularly if wrong dose administered;notify supervisor and/or school administrator, and school medical director;notify the parent/guardian; and complete a written report of the medication error detailing student's name, specific statement of the medication error, results of the school nurse assessment, who was notified, and what remedial action was taken. There is a sample Medication Incident Reporting Form on the NYSCSH website.

    Non-FDA Sanctioned Medication Requests
    Must a school honor a request to apply Essential Oils during the school day? Requests or orders for use of non-FDA sanctioned medicines including but not limited to, herbal remedies, dietary supplements, naturopathic or holistic medicines, and natural products do not need to be honored by a school district or school nurse. Schools should explain to the provider and the parent/guardian that such medications should be administered outside of school and document in the student’s cumulative health record.

    Over the Counter Medications (OTC)
    Do OTC medications require both parent and provider written permission to administer at school? Yes, all medications both prescription and non-prescription require provider written permission – with the exception of the 2 listed below.

    What 2 non-prescription medication orders do not require a licensed medical provider order? Sunscreen pursuant to Article 19 §907 of Education Law may be used with parent permission and alcohol based hand sanitizers may be used with an order from the school medical director.

    What happens if the provider order is for one brand of either prescription or non-prescription medication, but the parent/guardian brings in a different brand, is it acceptable for the nurse to administer it? If both brands are identical dosages (Advil and Motrin - both ibuprofen or Epi-Pen and Auvi Q both epinephrine) the school can accept and administer the medication.

    Opioid Antagonists
    What 3 options exist for schools wanting to incorporate Opioid Antagonists in their school policy? Option #1- Becoming a NYSDOH Registered Opioid Overdose Prevention Program. OPTION #2-Issuing a Non-patient Specific Order. OPTION #3 - Permitting Volunteers to be trained by a NYSDOH Registered Overdose Prevention Program. Please Note: Detailed instructions on the maintenance, inventory & storage, documentation, and notification requirements of a registered opioid overdose prevention program are available on the NYSCSH Opioid resource page.

    Prescription Medications
    May the nurse re-label a medication bottle if there is a change in the dose, time or frequency of the medication requested in writing by the provider and parent/guardian?  When the dose, time, or frequency of a medication is changed by a written provider order along with written parent/guardian consent, and the pharmacy bottle label does not reflect the new order, the nurse may label the bottle with the date, new dose, and/or frequency until a new pharmacy labeled prescription bottle is received. This is only permissible if the medication in the existing bottle can be used for the new order.

    What extra precautions should be taken upon receipt of controlled substances? A sample form may be found on the NYSCSH website by clicking here.  For certain medications, particularly controlled substances, standards of best practice include counting the medication upon receipt. Counting should also occur at regular intervals (e.g. daily or once/week) throughout the school year. Ideally a count of a controlled substance should be witnessed by another nurse, principal, or staff member designated by the principal.

    If a tablet does not come in the dose the provider ordered, may the school nurse split the pill? If the medication tablets are scored they may be split with a pill cutter. Using a pill cutter is necessary to ensure the pill splits evenly and does not crumble. Such scored tablets may be cut by a nurse prior to administration. Alternatively, the parent/guardian may request they are cut by the pharmacist. Tablets that are not scored should not be cut since they will not split evenly and the dosage will be unknown.

    Record Retention
    How long should student medication orders and parent/guardian consents be kept?  These records should be kept for one year after the end of the school year, as long as the information is transcribed into CHR on either an MAR or narrative. Medication orders and parent/guardian consents not transcribed, along with the MAR and narrative need to be kept in the cumulative health record by the school until the student reaches age 27. 

    Specific Diagnosis or Medical Considerations
    What new specific diagnoses or medical conditions have been included in the new Medication Guidelines? Diabetes Management,Blood glucose monitoring,monitoring of urine ketones or glucose, insulin administration, continuous glucose monitoring (CGM), Glucagon administration, Diastat, Epinephrine and Opioid Overdose Prevention Management have all been detailed on pages 28-35.

    Who may administer Diastat to a student? During a seizure, a student would be considered Nurse Dependent necessitating the medication be administered by a school nurse (RN), NP, PA, or physician due to the need for assessment to determine whether or not it is to be administered. However, in cases where a student has a consistent, predictable seizure pattern, an LPN under the direction of an RN may administer the medication. The LPN will need a detailed emergency action plan specifying the signs and symptoms that will warrant administering. If the RN is not on site with the LPN, the LPN must be able to contact the RN as needed, and the RN must be able to respond on site within 15 minutes.

    Staffing
    What does “under the direction of” mean for LPNs administering medications in the school setting?  Under the direction means the directing practitioner must provide an appropriate degree of direction to the LPN, which is determined by the care needs of the students, and the skill and ability of the LPN. The directing practitioner does not necessarily have to be on premises to direct an LPN where the directing practitioner is available to direct the LPN by telephone and can personally intervene within 15 minutes to ensure timely and appropriate care. (see #8 under RN and LPN, http://www.op.nysed.gov/prof/nurse/nursepracticefaq.htm)

    Stock Medication
    May schools choose to purchase and stock over the counter (OTC) medications for use by students and staff? This practice is not recommended, but it is not prohibited by law.   Schools choosing to stock medications must have written patient specific orders from the student’s provider and written parent/guardian consent permitting administration of stock medication. Stock medications for staff use, should be kept in a location other than the health office for staff to obtain if the school employs licensed health professionals. This is strongly recommended to eliminate any liability for the licensed health professional.

    May schools stock albuterol for use by students? Yes, if there is a patient specific order from their provider and written parent/guardian consent for albuterol that also authorizes the use of the school’s stock albuterol.

    May schools stock Potassium Iodide? School building administrators located in the ten mile emergency planning zones of nuclear power plants have been asked to participate in the Potassium Iodide (KI) Program. More information on the KI Program is available at: http://www.health.ny.gov/environmental/radiological/potassium_iodide/fact_sheet.htm

    Storage
    How should Medications be stored? Schools are not required to, but are strongly encouraged to utilize best practice double lock systems similar to those required in other health settings. Such systems include: being properly stored and secured within a health office cabinet, drawer, or refrigerator designated for medications only with a lock for the cabinet, drawer, and/or refrigerator as well as a lock to the outside health office door; should be secured to the wall or floor, and should not have breakable glass doors; being stored in a refrigerator used solely for that purpose to avoid cross contamination. The health office should always be locked when health services personnel or staff members trained to assist students are not present.

    Student Functional Categories
    What are the three functional categories of students when it comes to medication administration? They are -Nurse Dependent Students (formerly non-self-directed) -Supervised Students (formerly self-directed) -Independent Students (formerly self-administer and/or self-carry). Pages 8-10 of the medication guideline contain more information. A chart with the Levels of Assistance in Medication Delivery may be found here .

    What does Nurse Dependent mean? Students, who cannot self-administer their own medication and cannot be considered in need of supervision, are dependent on another person administering the medication to them. Nurse Dependent Students must have their medication administered to them by an appropriate licensed health professional.

    Who determines if a student can be considered Supervised? Students can be determined to need supervision either by the school nurse or the student's provider.  We have created a Sample Nursing Assessment for Determination of Supervised Students to assist the school nurse. Click here to view this form.

    Who determines if a student is Independent? The health care provider ordering the medication. The school nurse would not assess those student’s ability to be self directed or instruct them in self- administration It is recommend that they are instructed in how to safely carry on their person or store in a locker. On page 10 of the new guidelines we also include the need for an emergency care plan, and additional doses of medication in the health office for use as needed by the student.

    Students who require rescue medications for respiratory conditions, life-threatening allergies, or diabetes must be permitted to self-carry and self-administer their medications if they have what written permissions in place? A provider order and written parent/guardian consent for the student to self-carry and self-administer their medication pursuant to Article 19 Sections 916, 916-a, 916-b of Education Law must be in place. The provider order must also attest in writing that the provider has determined the student is able to self-administer their own medication effectively. Forms for this are on the website A-Z Resources, Medication subpage

    What about other medications which require timely administration?
    Independent Students with health conditions warranting rapid administration of their medications should also be permitted to self-carry and self-administer their medication to prevent negative health outcomes if they provide the same documentation as described above, and that any questions regarding such orders should warrant a telephone call by the school nurse or medical director to confirm the need for rapid administration warranting the student to carry the medication.

    Texting with Parent/Guardians about Medication (Text Messages for School Nurses: CAS Legal Mailbag Question of the Week – June, 2017 Answers from: SHIPMAN & GOODWIN Over 175 Attorneys Offices throughout Connecticut, New York & DC)

    Question: The typical public school nurse today most likely works with several students with severe and/or life threatening conditions that often require immediate attention. With the popularity and convenience of texting, many parents prefer to communicate via text regarding treatment for their child. For example, one mother of a second grade student with diabetes works during the school day and cannot take phone calls. She requests that the nurse text her with out-of-normal-range blood sugar levels of the student so that they may communicate about the student’s treatment. How is this practice affected by FERPA? Also, can any violation of FERPA be circumvented by the parent signing a waiver?

    Answer: As an initial matter, it would be prudent to first consult any board of education policies or regulations that may govern the use of text messages by employees for job-related purposes. Assuming no such board of education policies or regulations exist, aside from a true emergency when the school may need to use any means necessary to contact a parent, there are a number of reasons why the school nurse should not communicate with parents via text message about students’ medical needs and treatment.

    First, as you contemplate, the use of text messages for such a purpose could implicate the Family Educational Rights and Privacy Act (FERPA), which governs the confidentiality and disclosure of student education records and also provides parents the right to inspect such records. Under FERPA, an education record is defined as a record that directly relates to a student that is maintained by an educational agency (such as a school district) or a party acting for the agency. Text messages between a nurse and a parent about a student certainly would directly relate to that student, and although an unsettled question, one could argue that the nurse, who is a party acting for the agency, could be “maintaining” such text messages. Parents have the right to access their child’s education records under FERPA, and, therefore, a release from the parent would not be necessary to disclose information to the parent about the student. However, responding to a subsequent request by the parent to inspect all of the student’s education records related to the student’s health or treatment would be difficult if many of the records were contained on the nurse’s phone. The concern is then compounded by the possibility that the nurse may not retain the text messages, which might even be automatically deleted after a period of time.

    Regardless of the FERPA issues, however, the use of text messages for communication between the nurse and a parent regarding student health or treatment is ill advised. Communication between school nurses and parents about students’ health and treatment should be documented for a number of reasons, not the least of which is the ability to demonstrate that the school nurse acted appropriately or reasonably in a given situation and that he or she (and the district) properly implemented a student’s treatment protocol, Section 504 plan, or individualized health care plan. A text message thread between the nurse and parent could be inadequate for that purpose.

    Additionally, as noted above, there may be record retention problems with text messages. In addition to intentional or inadvertent deletion of text messages, phones die or may be lost or stolen; employees retire or resign, taking their phones with them; and employees may be uncooperative in providing access to their text messages. In short, retrieving and reviewing such text messages at a later date may be impossible. In addition, the school nurse likely would not want her phone and texts subject to a subpoena in a lawsuit or administrative proceeding initiated by a parent, which is always a possibility in our litigious society.

    Instead, a better solution for the nurse would be to use his or her school district email account to communicate with a parent who requests to communicate electronically rather by phone. Of course, such email communication should always be professional and with an appropriate level of formality. Emails create a clearer record, can easily be printed for a student’s file, and are much easier for the district to review and recover if needed. Moreover, if a parent is able to read and respond to a text message on his or her phone, he or she similarly should be able to read and respond to an email on his or her phone. If immediate communication is desired, the nurse can text the parent (or vice versa) with a notification that he or she has sent an email. In short, it is best for school nurses not to communicate about medical issues with a parent through text messages.

    Timing of Medication Orders
    When must a provider order be renewed? The order, which is valid for 12 months, should be renewed annually or when there is a change in the order. District policy should state whether new provider orders and parent/guardian consent is required at the start of the school year or when the order expires.

    Training
    If a school nurse is not familiar with certain medications or delivery methods, what should they do? She/he should inform school administration of the need for appropriate training in order to safely administer the medication. Schools must ensure they have the necessary training to meet the students’ needs, and are up to date in best practice. Therefore schools must seek out necessary training for staff and encourage and assist their licensed health professionals to regularly participate in professional development.  

    Who is responsible to train unlicensed personnel to assist Supervised/Independent students in taking their own medications? A sample form may be found on the NYSCSH website by clicking here. Training must be done by appropriately licensed health professionals and should be done in an organized manner and include how to assist the student; how to keep medications safe; how to document; the importance of confidentiality and should include a return demonstration. The training should be documented per district policy.If a student is independent but takes their medication in the health office, staff should be trained to hand them the bottle and review safe storage practices.

    May school nurses train unlicensed personnel to administer Epinephrine Auto-Injectors and Glucagon to students with orders? Yes, in accordance with Education Law Article 19 § 921-a, unlicensed personnel may be trained by an RN, NP, PA or physician to administer emergency epinephrine via auto-injector, or emergency glucagon to a student with a provider order. Such training must be done in accordance with specifications outlined in Commissioner’s Regulation 136.7

    Transporting Medication to School
    Who is responsible for transporting medications to school? The parent/guardian is responsible to have the medication delivered directly to the school in a properly labeled original container by an adult. In limited circumstances, a student who is not able to self-administer their medication may need to carry the medication on the bus in order to transport it to and from school for medical reasons or due to the family’s financial constraints. A written plan to ensure the safety of the student, as well as the safe transport of the medication should be developed in collaboration with the medical director or school nurse and the parent/guardian.

    Can an RN take a verbal order from a licensed provider? There is nothing in State regulation or statute that pertains specifically to school nurses in relation to verbal orders. As with any RN, school nurses may take a verbal order. We suggest the following procedure, but each medical director sets his/her own policy. The nurse should repeat the order to the provider for accuracy, have a second nurse verify by listening in (if possible), obtain the provider's signature on the written order within 48 hours

    Page updated 12/23/19

     

Last Modified on December 23, 2019