Nicholls State University
University Health Services
Policies and Procedures
I. Policy Statement
This Policy and Procedure Manual is designed to regulate and coordinate the activities of University Health Services (UHS). No policy or procedure shall be so construed as to violate or infringe in any way upon Nicholls State University’s policies and procedures, nor may policies be construed to infringe in any way on the powers and authority of the governing body of the University.
II. Statement of Mission and Goals
University Health Services (UHS) aims to advance the health of students by providing a wide spectrum of services, within a restricted budget. UHS is committed to integrating primary prevention with clinical health services and through referral, mental health services and nutritional counseling. We will strive to become the principle advocate for a healthy campus community.
- To provide a responsive medicine program so that health problems, illnesses, and injury may be assessed and treated or access to treatment is provided;
- To provide programs and information which make it possible for students to improve their own level of personal health and well-being;
- To be a part of the many resources available on campus for wellness activities; and
- To provide programs for the prevention of illness and injury.
III. Eligibility of Services
Any current full or part-time student or employee of Nicholls State University (NSU) may request health care from University Health Services. NSU employees may also access UHS for healthcare for work-related injuries, filing incident reports, blood pressure checks, and they also may participate in health/wellness screenings or programs as offered. Retired NSU employees may also participate in wellness and screening events.
Visitors to the NSU campus may access UHS for healthcare related to injuries, emergency healthcare needs, and acute illnesses which occur on campus.
IV. Description of Services
University Health Services is an ambulatory health care facility which treats acute illnesses and any sudden onset of symptoms of a chronic illness or disease. Patients with chronic or long-term health problems will be referred to the appropriate physician or health care agency. As an element of the University’s Early Return to Work Policy, UHS will evaluate and, within the department’s scope of services, treat employees who are injured while on the job.
University Health Services’ Health Education Office coordinates and promotes various educational sessions and activities on the NSU campus.
V. Appointment Scheduling Procedures
All patients requesting to see a nurse or doctor/nurse practitioner should schedule an appointment in advance. (See Appointment Books) Doctor/nurse practitioner appointment availability varies by day and by semester. Nurse appointments are available all day.
When scheduling an appointment, it must be determined if it is a nurse appointment or a doctor/nurse practitioner appointment. Appointments such as TB skin test, Hepatitis B vaccine, and blood pressure checks are considered routine appointments that can be scheduled for a nurse. Most other presenting problems should be scheduled for a doctor/nurse practitioner appointment. If the patient can only come in when the doctor/nurse practitioner is not available or has an emergency condition an appointment with a nurse should be scheduled.
The patient’s name, campus ID number, the reason for visit, and a phone number are recorded in the respective appointment book (doctor or nurse). If the patient has been seen in UHS before, the chart number is entered in the blank labeled “Chart #” on the appointment schedule. If the patient has not been seen at UHS before, the blank labeled “Chart #” is filled in with the word “New.”
VI. Maintenance of Medical Records
1) Handling of Medical Records
At the start of each business day, the secretary will review the appointment book and pull medical records for those patients scheduled for appointments that day. These files are organized in order by appointment and placed in the doctor/nurse appointment box which is located on the wall in the chart room. As each patient arrives for his/her appointment, the medical record is given to a nurse and the patient is assessed by the doctor/nurse practitioner. After the visit is over and the notes for that visit are complete, the medical record is placed in the designated “To File” box in either the Medication Room or the chart room. At the end of the day, the secretary will note any missed appointments based on the files remaining in the appointment boxes in the chart room.
2) Medical Record Procedure
Confidential medical records will be kept on each individual utilizing the UHS. Medical records for students and visitors will remain on file for ten (10) years (after the last entry date), and they will be kept for thirty (30) years after an employee’s last employment date, per employer requirements. After the designated number of years, the medical records will be destroyed. Only the University Health Services staff will have access to these confidential medical records. Both student and employee medical records are stored in a locked chart room.
Both student and employee charts are filed numerically by the last two digits of the chart number first and then the first three digits of the chart number in the chart room. A chart must be pulled verifying that the name and social security number match the name and social security number of the patient being seen.
After charts are pulled they are then prepared for the visit with the nurse or doctor/nurse practitioner. Preparation consists of verifying that there are sufficient lines remaining on the yellow chart record sheet for the nurse and doctor/nurse practitioner to record the current visit information. If needed, a new yellow chart record is inserted with name, social security number, and chart number recorded in the proper area on both sides of the sheet. The appointment date is stamped in the proper area, leaving no blank lines, on the chart record sheet.
A Patient Procedure Record is then prepared recording the date and time of the appointment and the demographics of the patient. The sheet is placed inside the chart.
1. The Patient Procedure Record (PPR) is to be used as a hardcopy for recording University Health Services’ (UHS) statistical data on computer for the purpose of tracking the number of patients seen, patient demographic data (male/female, full-time student/part-time student/employee, etc.) and the number of chargeable services administered.
Charts should be pulled and prepared a day in advance for all scheduled appointments.
The patient’s chart should be arranged in the following order:
ii. Left Side (first to last with duplicates and like items in chronological order with most recent on top):
1. Medical Summary List (s)
a. The Medical Summary List is used as a condensed profile of the patient’s medical history, and as a synopsis of previous medical problems treated at UHS.
2. Medical Questionnaire
3. Athletic Physical (s)
4. Immunization Record (s) including, but not limited to:
a. Mantoux (TB) Test results
b. Hepatitis B Vaccine Record or Titer
7. Release of Information Consent (s)
8. Subpoena of Information
iii. Right Side (first to last with duplicates and like items in chronological order with most recent on top):
1. Chart Record (s)
a. The Chart Record is utilized for the recording of patient observations and treatment(s) by the medical and/or nursing staff of UHS.
2. Patient Assessment Sheet (s)
3. Athletic Exam Report (s)
4. Lab Report/Request (s)
5. X-ray Report/Request (s)
6. ER Report (s)
7. Surgical Permit (s)
8. Against Medical Advice Form (A.M.A.)
9. Correspondence from physicians/medical clinics concerning patient’s medical history, physical condition, etc.
10. Any other documents/information that are part of a patient’s treatment.
VII. University Required Immunization Compliance
According to Louisiana Law (R.S. 17:170 Schools of Higher Learning), all first-time college students born after 1956 must provide proof of specific vaccine preventable diseases. Students not meeting this requirement will be prevented from registering for subsequent semesters. Required vaccinations include:
- Two (2) doses of measles vaccine,
- at least one (1) dose of each rubella and mumps vaccine, and
- Tetanus-diphtheria booster (at least 10 years current).
Students must provide proof of immunization to University Health Services. The student should provide either a completed Proof of Immunization Compliance form or a copy of his/her immunization record from a public health clinic, physician’s office, military, or other.
In the event that the student requests to be exempt from receiving the required vaccinations, s/he should complete theRequest for exemption form. The student should provide a reason for the request, his/her Signature and Date. If the student is a minor, his/her Parent or Guardian must also provide a Signature and Date.
VIII. Clinical Compliance for Students in the Department of Nursing & Allied Health
Students enrolled in the Department of Nursing and Allied Health must participate in clinical experiences in order to fulfill their course requirements. Nursing students participating in clinical experiences must meet both the university and clinical agency’s immunization requirements. The requirements must be fulfilled prior to the student beginning their clinical assignment. The Department of Nursing, via the student’s handbook, (See attached Department of Nursing’s Requirements Prior to Entering Clinical, Adopted 2/92, Revised 1/99) is responsible for communicating requirements to the student.
It is the student’s responsibility to provide documentation of the required immunizations/test results in a timely manner prior to the start of clinicals.
It is the responsibility of University Health Services to verify the student’s compliant/non-compliant status.
IX. Incident Reporting/First Aid Log
University Health Services will serve as an initial contact point for students, faculty, staff and visitors when an injury or accident occurs on campus or during a university event. The Incident Report will serve as documentation for University purposes and will not be a part of a patient’s medical record. The Incident Report will be communicated with necessary departments on campus.
X. Emergency Procedures
In the event of an emergency on campus, University Police will respond to the emergency first and evaluate the situation. University Officers are trained first responders and have first aid equipment and an automated external defibrillator (AED), which was supplied by University Health Services.
1) If the subject who is in need of emergency care that is beyond the training of the university police officer and is life threatening, an ambulance needs to be requested.
2) If the subject’s medical needs are such that Health Services can assist with, the officer will have dispatch notify Health Services that they are en route with the person and provide a description of the condition and possible medical needs of the patient.
i. If the patient has been seen in UHS previously, the patient chart should be pulled. If they have not been seen previously, a new patient chart should be opened.
ii. If the emergency involves an accident or incident, an incident report should be completed.
3) If the subject needs to be transported to the Hospital for a minor injury that requires an emergency room evaluation, the officer is to transport the subject to the emergency room as normal and have dispatch notify Health Services of the situation.
*Note* At any time a subject needing medical treatment and is refusing to be transported by us (University Police), the officer is required to have the subject sign a refusal to be transported on department form.
All officers are trained and must perform CPR, First Aid and AED treatment (when instrument is available) on subjects needing assistance.
Each employee of University Health Services will read and discuss with his/her supervisor the rules on confidentiality of information. After this is done, the employee will be required to sign a Confidentiality Statement which will be kept on file in the University Health Services. If at any time the employee knowingly breaches the confidentiality rule, he/she can be subject to firing.
When handling financial and personal information about students, employees, or others with whom NSU has dealings, the following principles should be observed:
1. Collect, use, and retain only the personal information necessary for NSU’s business. Obtain any relevant information directly from the person concerned whenever possible. Use only reputable and reliable sources to supplement this information.
2. Retain information as long as required by law and in accordance with University policy. Protect the physical security of this information.
3. Limit internal access to personal information to those with a legitimate business need for seeking that information. Use only personal information for the purposes for which it was originally obtained. Obtain the consent of the person concerned before externally disclosing any personal information, unless legal process or contractual obligation provides otherwise.
4. Compliant with the Family Educational Rights and Privacy Act (FERPA) (www.nsula.edu/registrar).
5. Compliant with the Health, Insurance, Portability, and Accountability Act (HIPAA).
XII. Against Medical Advice (A.M.A.) Form
The Against Medical Advice Release form of University Health Services should be used as the document of last resort in the event of a patient refusing medical treatment, part of a treatment or transport to outside services (e.g. Thibodaux Regional Emergency Department). If the patient requires medical treatment, in the opinion of the healthcare provider, then the nurse and/or physician/nurse practitioner should assure that the patient understands the need for the treatment, the nature of the medical problem, and the possible complications of not receiving treatment. The AMA form must then be signed by the patient and by two witnesses.
In the event that the nurse and/or physician/nurse practitioner encounters a patient that refuses treatment, the following procedures should be followed prior to obtaining the patient’s signature on the AMA form:
1) Document the patient’s ability to comprehend the verbal information concerning the present medical condition as described.
2) Inform the patient of the problem, or your perception of the problem, and document this information on the run report.
3) Inform the patient of the complications and consequences of not seeking medical treatment and document this information.
4) Suggest possible alternatives to the patient, such as seeking the assistance of family member to help in obtaining medical treatment.
5) If the above procedures do not convince the patient to seek further medical treatment, then have the patient sign the Against Medical Advice Release form.
6) If the patient refuses to sign the AMA form, then document the refusal and have two witness sign that they have witnessed the refusal.
7) Inform the patient at any time if he/she decides to receive the treatments recommended, he/she is eligible for the said treatments.