Nurses Notes/

Specialties School

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Looking for any thoughts, suggestions. I currently do not have a computerized charting system. Our district (3 schools) may be looking into this in the future, but for now I am really struggling keeping up with paper notes.

I tried doing a Word Page for each student (about 55 kids) in January, and it worked well and was much more efficient for me. BUT, it's not secure, and I thought I had to print it all out, sign each note and place in my binder. A lot of time!

Thinking I might try a flash drive that is dedicated strictly to nurses notes, and lock it at the end of each day. I am wondering about the legality (I am in NJ) of not physically signing notes. How does that work when you use a computerized nurses note? I am worried that someone can say "well, you went back and changed something."

Any thoughts appreciated. I need to document every phone conversation and every step in my office, and am struggling.

Thanks!

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Specializes in IMC, school nursing.
Looking for any thoughts, suggestions. I currently do not have a computerized charting system. Our district (3 schools) may be looking into this in the future, but for now I am really struggling keeping up with paper notes.

I tried doing a Word Page for each student (about 55 kids) in January, and it worked well and was much more efficient for me. BUT, it's not secure, and I thought I had to print it all out, sign each note and place in my binder. A lot of time!

Thinking I might try a flash drive that is dedicated strictly to nurses notes, and lock it at the end of each day. I am wondering about the legality (I am in NJ) of not physically signing notes. How does that work when you use a computerized nurses note? I am worried that someone can say "well, you went back and changed something."

Any thoughts appreciated. I need to document every phone conversation and every step in my office, and am struggling.

Thanks!

My IT guy set up a super simple word document that has contact info, medical info and documentation. Very rudimentary, but it can be password protected. I use the same password for every kid, maintain a template and keep all students in one folder on my computer. If you PM me with your email, I could send you the template. I only have 112 kids. I flash drive the years so I have records.

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Specializes in School Nurse. Having conversations with littles..

Linda- I have made up a nurses note that I just keep in a 3 ring binder. One for each student. I have a lot of things on it, so I just circle the complaint and what I did and/or write in what is necessary. I would be happy to share that with you if that would be helpful at all. The form also has a place for communication.

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Specializes in school nursing, ortho, trauma.

I use health master's health office anywhere and i really like it. It's got everything i need - and even Audit trail to keep the courts happy in case i change something. But it's a cost and schools are penny pinchers.

Does the rest of the school use a computerised system for grades and schedules? Sometimes they have a health module. It's not as nice as Healthmaster or SNAP, but it's easier than what you're doing if your school already has that in place. And the health module shouldn't cost much more (or anything at all)

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Thanks to all of you for your input. Sent PM's. Apparently they looked at a computerized program a few years back, before I arrived, but no decisions were very made. Time to look at it again!

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