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Record Keeping

When staff administer medication a record must be made of the date, time and dose, and this record must be signed on the medicine consent form.  Reasons for any non-administration of regular medication must be recorded and the parent/carer informed on the same day.  The consent form must be kept with the medication.

All schools/settings should have a medicine policy which is shared with parent/carer and indicates what staff will do in regard to routine and emergency medication administration. The policy should reflect procedures for who will give any medication, how the medication will be stored, recording how you give medication, training staff if there is a specific medical need. (See attached for a suggested framework.)

An individual care plan clarifies for parent/carer, the child and school/setting staff the circumstances in which additional health support will be required and the actions to be taken by school/setting staff to meet the pupil’s needs.  They should be developed with the child’s best interests in mind and ensure that the school assesses and manages risks to the child’s education, health and social wellbeing, and minimises disruption. Where the child has a special educational need identified in a statement or Education and Health Care Plan (EHCP), the individual healthcare plan should be linked to or become part of that statement or EHCP. The care plan will be developed with input from a health professional, a parent/carer/pupil and a member of school/setting staff depending on the nature of the pupil’s condition.  Specialist guidance may be sought from the child’s GP, Consultant or Nurse Specialist. Under the Data Protection Law medical documents are deemed sensitive information.  The information in the care plan and/or related medical information where a care plan is not necessary, needs to be disseminated to relevant staff but balanced with the need to keep confidential information secure.  Care plans must not be displayed in a public place, e.g. staff room, because of the sensitive information they contain unless there is a clear, justified need to do so and the parent/carer has also given their explicit written consent for this. Where appropriate, pupils should also be consulted. The care plan supplied is a guide to the type of information required and may be expanded as required by the child’s condition and the nature of the treatment to be given.  The care plan must be kept up to date and should be reviewed on a regular basis to reflect the pupil’s needs.  It should certainly be reviewed annually.  A new care plan is required if a child moves school/setting or their condition or treatment changes.

All early years settings must keep written records of all medicines administered to children and make sure that parents are informed on the same day or as soon as reasonably practicable. The statutory retention period for early years records is two years.  For schools, the recommended retention for these records is the date of birth of the child being given/taking the medicine plus 25 years.  This allows for records to be kept as evidence for litigation should the child on reaching 18 years old feel this is something they want to pursue.