216 R.I. Code R. 216-RICR-20-10-4.18

Current through November 21, 2024

Section 216-RICR-20-10-4.18 - Health Records

A. The school nurse is responsible for the complete, cumulative school health record for each student at the school in which the student is enrolled. The health record must include:

1. Immunization status;

2. Health history, including chronic conditions and treatment plan;

3. Screening results and necessary follow-up;

4. Health examination reports;

5. Documentation of traumatic injuries and episodes of sudden illness referred for emergency health care (see also requirements in "First Aid and Emergencies" § 4.21 of this Part);

6. For a student with documented anaphylaxis, the parental authorization of a student's treatment for allergies and the physician's order to administer an epinephrine auto-injector must be entered into the student's health record.

7. Documentation of any nursing assessments completed;

8. Documentation of any consultations with school personnel, students, parents, or health care providers related to a student's health problem(s), recommendations made, and any known results;

9. Documentation of the health care provider's orders, if any, and parental permission to administer medication or medical treatment in school by the school nurse.

B. The student's cumulative health record is confidential and subject to the provisions of R.I. Gen. Laws Chapter 5-37.3, ("Confidentiality of Health Care Information Act"), and other applicable State and Federal laws and Rules and Regulations.

C. The record must be stored in an appropriately secured location with convenient access by the school nurse and must be used only in connection with the provision of treatment to the student.

D. Appropriate steps must be taken for the protection of all student health records, including the provisions for the following:

1. Securing records at all times, including confidentiality safeguards for electronic records;

2. Establishing, documenting and enforcing protocols and procedures consistent with the confidentiality requirements of R.I. Gen. Laws Chapter 5-37.3 and this Part;

3. Training school personnel who handle student school health records in security objectives and techniques.

E. The record must be maintained by the school for a minimum of five (5) years after the student turns eighteen (18) years of age or five (5) years after the student leaves the school district.

4.18.1Confidentiality

A. Any school personnel, including health care providers, who maintain cumulative school health records containing confidential health care information are responsible for ensuring full confidentiality of this information as provided in R.I. Gen. Laws § 5-37.3-4 ("Confidentiality of Health Care Information Act") and other applicable State and Federal laws and Rules and Regulations.

B. Any school personnel, including health care providers, who release confidential health care information from cumulative school health records in accordance with R.I. Gen. Laws § 5-37.3-4 ("Confidentiality of Health Care Information Act") and other applicable State and Federal laws and Rules and Regulations, must document each release in the cumulative school health records by indicating the following:

1. The date of release;

2. A description of the information released;

3. The name(s) of the person(s) to whom the information was released;

4. The reason for the release of information.

C. Violations Pertaining to Confidentiality: Any person suspected of violating the Health Care Information Act must be reported to the Attorney General's Office for prosecution and any subsequent penalties, in accordance with statutory provisions.

4.18.2Transfer of Health Records

A. Whenever a student transfers to another school building or school system in or out of Rhode Island, the original, a copy, or electronic version of the complete, cumulative school health record must be transferred at the same time to the health personnel of the school building or school system to which the student is transferring.

B. This record must be sent in a manner consistent with the provisions of the Health Insurance Portability and Accountability Act (Pub. Law 104-191) to a health care professional authorized to receive confidential health care information at the new school or handed to the parent, as appropriate.

C. A copy of the record (or the original) must be maintained by the community for a minimum of five (5) years after the student turns eighteen (18) years of age or five (5) years after the student leaves the school district.

216 R.I. Code R. 216-RICR-20-10-4.18

Amended effective 4/11/2022