BEST PRACTICE: Procedures and Protocols




The following procedures and protocols have been developed for the school environment and have been formulated in a layout often used within the school setting. They are a starting point and do not reflect a comprehensive list of all procedures and protocols required in a School Based Health Centre (SBHC). In some instances the documents have been adapted from a variety of sources using a combination of many authors and in those instances it is difficult to accurately reflect the original authors for these blended documents.

While designed to reflect best practice, they are available to be adapted to each school to ensure the needs of your specific community are met. The documents are created in word so that can be saved directly from the disc and then adapted as necessary. In areas where text is placed in <<text>>, replace your school’s details.

For ease of reference, procedures and protocols have been alphabetically placed in categories.

ABUSE & NEGLECT

Abuse & Neglect
This procedure outlines the philosophy, prevention and intervention strategies for abuse and neglect. Definitions are provided, and it covers abuse in the community and by staff (Original authors CMDHB Policy Team, adapted with permission by SBHS Team, 2005, revised ASNG, 2012) HERE

Child/Young Person Protection
SBHC staff have an important role and responsibility in accurate recognition at an early stage of child/young people abuse or at risk of abuse, and adults at risk of abusing children/young people (Original authors CMDHB Policy Team, adapted with permission by SBHS Team, 2005) HERE

COMMUNICATION

ISBAR
A communication tool for health professionals ISBAR (Identify, Situation, Background, Assessment and Recommendation) is a mnemonic created to improve safety in the transfer of critical information. It originates from SBAR, the most frequently used mnemonic in health and other high risk environments such as the military. The “I” in ISBAR is to ensure that accurate identification of those participating in handover and of the health consumer is established. HERE



CONFIDENTIALITY

Confidentiality
The SBHC undertakes to provide confidential health services to clients/students in line with current legislation and will ensure clients/students are aware of their rights within that service. (Original authors CMDHB Policy Team, adapted with permission by SBHS Team, 2005, revised ASNG, 2012) HERE

Disclosure of Information from Enrolment
To ensure that appropriate school staff has access to relevant health information of the students/clients they come into regular contact with to ensure student health issues do not compromise their learning opportunities (SBHS Team, 2005) HERE


CULTURAL

Maori Health – Maori Kaupapa Hauora (Original authors ADHB, adapted with permission by Othauhu College, 2010. Revised ASNG, 2012) HERE


DOCUMENTATION

Documentation in the Clinical Record
Clinical documentation is the mechanism for recording and communicating the clinical status of the student/client to all members of the health care team, to ensure that the communication among health care providers is documented accurately and comprehensively (Original authors CMDHB Policy Team, adapted with permission by SBHS Team, 2005. Revised ASNG, 2012) HERE

SOAP is an assessment tool to document effectively in the clinical notes. Obtained from www.southernct.edu HERE

Correcting Inaccuracies in the Clinical Record
All health information in the clinical record must be accurate. However, from time-to-time inaccuracies are identified, and these must be corrected to ensure the records remain accurate. This procedure outlines the processes to ensure that when corrections are made they are tracked, clearly identifiable, and by whom they were authorised (Original authors CMDHB Policy Team, adapted with permission by SBHS Team, 2005. Revised ASNG, 2012) HERE


INFORMED CONSENT


Informed Consent: This procedure provides a framework for obtaining informed consent from clients and others consistent with the Code of Health and Disability Services Consumers’ Rights 1996 (“the Code”). Informed consent should be considered as the exchange of information so that an informed decision to consent to or refuse treatment can be made by a client or that client’s legal representative (Original authors CMDHB Policy Team, adapted with permission by SBHS Team, 2005. Revised ASNG, 2012) HERE


MEDICATION

Administration of 'General Sale' Medication
Clear guidelines to support the Registered Nurse on the administration of routine general sale medication to students/clients (SBHS Team, 2005. Revised ASNG, 2012) HERE

Administration of Prescription Medication
Clear guidelines to support the Registered Nurse on the administration of medication prescribed by a General Practitioner or Specialist of routine, or emergency prescribed medication to students/clients (SBHS Team, 2005. Revised ASNG, 2012) HERE


SEXUAL HEALTH

This procedure is based on the School Board of Trustees philosophy, with respect to and recognition of the schools special character, culture and community. All students who request help with issues relating to sexual health and sexuality will be treated with dignity and respect, and be provided with advice and support. This document applies to School Based Health Centre staff and visiting Health Practitioners (SBHS Team, 2005. Revised ASNG 2012) HERE


Reviewed March 2012
Updated March 2015


Best Practice
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