New school nurses are finishing up topic 3 in their Moodle class and so I have been reviewing many Special Education Health Evaluation Reports. It has been a few years since I sent out information or directions on how to complete these reports, I thought I would take this opportunity to provide a refresher. Let's start with a bullet list of requirements:
• A Health Report is only required for special education students with a positive health screen who are being evaluated for initial eligibility for special education. (For students who are already staffed in special education, the findings from a first official health evaluation may be noted either on the report template or directly in the web IEP on page I.)
• All reports must be written in complete sentences. (This is a professional report and not charting so avoid brief phrases and inclusion of subjective data.)
• Either avoid the use of medical abbreviations or write them out once and then reference. (Readers of our reports are primarily parents and teachers.)
• Avoid the use of technical terms as well. If needed, you may also explain the meaning of such terms.
• If you do not use the Heartland template for your report, you still must address all areas covered in the template using complete sentences and transitions between topics.
• If you use the template, fill in all information requested and read the directions. For exams, you will need to list the date, examiner's name and title, as well as the results.
• An emergency plan is not the same as an individual health plan (IHP). It is only an intervention as part of the IHP. You must provide your nursing diagnosis as part of the report when an IHP is needed.
• An alternate emergency plan is required when a student needs any special assistance during an emergency drill or evacuation.
The report is divided into three major sections to correlate with special education requirements. Our report details progress, discrepancy, and need as it related to the domain of health. The first section is titled, "Educationally Relevant Past Medical and Developmental History". There we must address the students' progress over time in these two areas. Loosely, it correlates to a past medical history but we must include both positive and negative findings. Since our primary audience contains parents and teachers we need to list both types of findings to demonstrate the depth of our nursing assessment. For example, "Ian met all developmental milestones within accepted age limits and he has no chronic health conditions, according to his mother." Another example might be, "Review of pediatrician records since birth, note that Jon met all developmental milestones within normal age limits. At age three he was diagnosed with diabetes."
"Current Health Status" is a 24 hour per day look at all medications, treatments, and upcoming procedures that are unique to the student. Discrepancy from healthy peers is the focus of this section. Medical orders and records will be helpful, especially if the student will require special health services at school. Think of this section as filling in the gaps for what happens outside of school. While there is some overlap between this section and the final one, try to minimize duplication. Think of this section as a overview and the final one as providing details for writing page F of the IEP. Here is a brief sample, "Emily has moderate persistent asthma and is followed by Dr. Sheets at Blank. She uses her Flovent inhaler 2 puffs, twice per day at home. She has required the use of oral steroids once already this fall for a severe asthma flare. She has not been hospitalized in over a year related to her asthma. Other medications include..."
The sole purpose for conducting the health evaluation is to determine what needs, if any, the student has that must be addressed. These needs are summarized in the section titled, "Student Health Needs During the School Day". When thinking of the needs, interpret broadly to include the bus ride, recess, lunch, field trips, and, for older students, extracurricular activities including school sponsored sports and competitions. While the first page of the report includes the health, emergency, and emergency evacuation plans, it is also a good idea to mention these again in this section. Remember that a special education student will never have both an IEP and a Section 504 plan. For any child with a chronic health condition, include all necessary accommodations on page F of the IEP and not in your IHP. You may list potential accommodations or the lack of independence in this section of your report but the entire team makes the decision as to how to meet this need. For example,
" Mike is dependent on adults for all activities of daily living. He requires two tube feedings during the school day at 10 am and 2 pm. No medications are administered during the school day. Mike uses a wheelchair for mobility and he is learning to drive it with a head switch. He is incontinent and wears pull-ups. Rectal diastat will be needed in the event of a seizure lasting longer than three minutes. The bus attendant, teacher, and classroom associates have all received training in seizure recognition and first aid, in addition to how to administer rectal diastat, when needed. Training was also given to the teacher and associates related to administration of a tube feeding. Nikki Pete DPT provided a demonstration for the teacher and associates in how to safely transfer Mike into and out of his wheelchair. An IHP, emergency plan, and alternate emergency evacuation plan are all on file in the health office and copies are located in the special education room."
For questions related to the health evaluation report, contact your assigned nurse consultant.