Assessment findings listed and appropriate Parent notification documented VS recorded as appropriate Confidentiality maintained Procedure details recorded IHP referenced Parent Name documented Treatment authorization verified Medication administration details Staff notification if needed Parent contact information documented Health history referenced Athletic clearance if appropriate Out time No abbreviations Allergies noted Clear discharge instructions Correct template as appropriate VS recheck recorded as appropriate Clinic visit outcome provided Chief complaint recorded RAD Complete In Time Billable duration 5 minutes + Interventions Provided Student's response to treatment Follow up plan documented Parent contact attempt and times Return to class/dismissed early Documented Student's verbal description noted Assessment findings listed and appropriate Parent notification documented VS recorded as appropriate Confidentiality maintained Procedure details recorded IHP referenced Parent Name documented Treatment authorization verified Medication administration details Staff notification if needed Parent contact information documented Health history referenced Athletic clearance if appropriate Out time No abbreviations Allergies noted Clear discharge instructions Correct template as appropriate VS recheck recorded as appropriate Clinic visit outcome provided Chief complaint recorded RAD Complete In Time Billable duration 5 minutes + Interventions Provided Student's response to treatment Follow up plan documented Parent contact attempt and times Return to class/dismissed early Documented Student's verbal description noted
(Print)
Assessment findings listed and appropriate
Parent notification documented
VS recorded as appropriate
Confidentiality maintained
Procedure details recorded
IHP referenced
Parent Name documented
Treatment authorization verified
Medication administration details
Staff notification if needed
Parent contact information documented
Health history referenced
Athletic clearance if appropriate
Out time
No abbreviations
Allergies noted
Clear discharge instructions
Correct template as appropriate
VS recheck recorded as appropriate
Clinic visit outcome provided
Chief complaint recorded
RAD Complete
In Time
Billable duration 5 minutes +
Interventions Provided
Student's response to treatment
Follow up plan documented
Parent contact attempt and times
Return to class/dismissed early Documented
Student's verbal description noted
