The fact that a student has sustained an injury is determined by the need for either first aid or some type of medical treatment, other than diagnostic procedures. The purpose of body checks and diagnostic procedures (e.g., examination, x-rays, etc.) is to determine whether an injury has occurred, and/or the extent or severity of an apparent injury.
If neither first aid nor medical treatment is required, there is no injury.
If it is determined by a medical provider that the student has sustained an injury, it still must be determined whether the injury is a minor or a major injury.

a. MINOR INJURY
A minor injury is defined as”…one which requires only first aid to be provided on site”.
(OCCS communication, March 2000).

According to this definition, if on site (e.g., nurses station) first aid (non-diagnostic procedures) is necessary for the injury (e.g., ice pack, Bandaid), the student has received a “minor injury”.
If the student does not require first aid, even if a body check or examination has been conducted, the student has not received a minor injury.

b. SERIOUS OR MAJOR INJURY
A serious or major injury is defined as “…one which requires a visit to a physician, ER or hospitalization”. (DEEC communication, March, 2000).

If it is determined that the student should be sent to a community physician or to the ER to determine if an injury has been sustained, and the extent of that possible injury, the act of sending that student to a community provider does not in and of itself result in a classification of “major injury”.
If the student receives a diagnostic examination and either receives subsequent medical treatment for an injury that goes beyond first aid, or is hospitalized for medical treatment of an injury (rather than for additional diagnostic work), the student has received a “major injury”.
If the student receives a diagnostic examination without receiving medical treatment because no injury was sustained, the student has not received a major injury.

If the student receives a diagnostic examination and, subsequently, only first aid because the injury was minor, the student has received a “minor in jury”, and not a “major injury”.

c. DOCUMENTING RESTRAINT RELATED BODY CHECKS AND INJURIES
1. The injury notation on the Physical Intervention form should be completed in a manner consistent with these definitions.

2. It is sometimes necessary to restrain a student more than once and sometimes with little time in between restraints and before a body check can be conducted. In such cases the body check and finding (e.g. “minor injury”) will be documented only on the most recent or last Physical Intervention Report form for the series, even though there will be a PI form completed for each restraint (incident).
On the most recent or final PI form in a series, the nurse conducting the body check will include the following note: “Body check for multiple physical interventions”.
On all other PI forms in that same series, the nurse conducting the body check will include the following note: “See the most recent PI form” with both date and time of the final PI form noted.
Sequential PI forms should be clearly marked to show the sequence of events.

3. If the student is sent to a community physician or to the ER for diagnosis and/or treatment of possible injury, the nurse does not complete the PI form related to injury until the final determination has been made by the community based provider as to whether an injury occurred and the extent of any injury.
In this case, the Nurse notes the action in the Medical Attention comment section (e.g., sent for X-Ray on 5/12/07) and circles the right hand section regarding injuries. She/he does not check off any injury box until the form is retuned for completion and the determination is made as to whether there was an injury.
The form is then circulated as usual.
Given these types of notations, after signing off on the form, the last person to review the form returns the form to the Nursing for completion.
When the form returns to Nursing, the nurse will complete the form in a manner consistent with the findings, including any explanatory notes and check offs (no injury – in which case the entire section is Xed out, minor injury or major injury), and the form is routed to the person who enters PI/injury data before the form is filed.