Uniform Health Records are required to be kept by school administrative units. This requirement is outlined in CMR 05-071, Ch 126, Immunization Requirements for School Children (a joint rule with the Department of Health and Human Services, Center for Disease Control and Prevention, Ch. 261): “each school/unit is required to adopt a uniform student health record for maintaining information regarding the health status of each child as defined under Section 1.” The student health record is defined as “documentation of health information and school nursing services provided to individual students including, but not limited to, immunizations, health screening, health assessment and nursing care plans, as needed.”
SAUs can meet the uniform health record requirement through the use of a paperless record, either through the use of a stand-alone electronic health record (EHR) solution or through an added module to the student information system. Paper solutions are also acceptable.
SAUs should take the following steps:
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Determine what the uniform student health record is in your SAU
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Make plan for uniform health record moving forward. Options are listed below:
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Adopt an EHR
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Adopt a health module within student information system
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Use a manila file folder using the template cover sheet provided here. It can be printed on a 5 ½ x 8 ½ inch label (two per sheet).
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As a reminder, when a student transfers out of one SAU, it is required by 20-A MRS Section 6001-B to send the entire student record to the receiving school unit while ensuring student privacy laws are maintained.
Please contact DOESchoolandStudentSupports@Maine.gov with any questions.
National Association of School Nurses Documentation Resources
Template Health Record Cover Sheet to be used on a plain manila file folder (Print on Half Sheet Self Adhesive Shipping Labels, 8.5" x 5.5" [2 labels per page])
Outbreak Reporting to CDC
A potential outbreak of disease is reportable to Maine CDC. In schools, this is defined as 15% of the school population being absent on a particular day due to illness. Schools must report elevated absenteeism. This reporting tool will complete this report to both DOE and Maine CDC in one step. For step-by-step directions see the NEO Reporting Reference Guide.
Yearly Reports
The annual mandatory reporting items for school health relate to medication, hearing and vision screenings, and immunizations.
Immunizations Summary Report
In accordance with Chapter 126/261, all schools must submit a summary report which will include the following information at a minimum: specific information identifying the school, the superintendent; the total student enrollment, the number of new students identified by vaccine type, as either immunized, exempt or out of compliance, and the number of students who are enrolled and un-immunized. Each report shall be signed by the school superintendent as a certification that the information is accurate and complete.
The Maine Center for Disease Control and Prevention will, from time to time, select a small sample of student health records for the purpose of comparing reported results against the criteria delineated in these rules. The results of this sample survey will be shared with school superintendents for the purpose of identifying problem areas that may be occurring in the completion of their school health records. Individual students are not be identified. Contact the Maine Immunization Program, Maine CDC for more information. You can access these reports on the Maine Immunization Program Immunization Assessment Reports webpage.
School Health Annual Report
Each spring, the Department of Education collects the School Health Annual Report from all schools. Data helps build bridges that connect school health services to the rest of the health care system. This data collection will help to demonstrate their unique and critical contributions to the health of school-age children and their academic achievement. The report is made of up both required and optional data points. Despite being optional, the information requested is vital to understanding and improving the work conditions and outcomes desired by Maine’s school health services workforce. When open for submissions, the School Health Annual Reporting link can be found in the Reporting Calendar.
Optional, but recommended Reporting Section for ALL Maine schools, public, private, and charter. The goals of Every Student Counts™ are to develop a robust national school health data set that will influence local, state, and national student health policy, as well as identify best practices in school health.
Contact
Emily Poland, MPH, RN, NCSN
School Nurse Consultant
Coordinated School Health Team Leader
Email: Emily.Poland@maine.gov