School Health Room Log

[pugmomrn]

Our schools currently use a daily health room log-- all students are recorded on the same sheet. Very basic info- time in/out, "brief description" of complaint/intervention, discharged to class/home. While it is very easy to tally it all up for my monthly stats and to track trends in illness across the schools on a given day, it is a wee-bit noncompliant with everything we ever learned as far as health records! Plus, it is difficult to track a particular student's HR visits without paging through stacks of papers.

Our schools' computer system would allow HR visit info to be entered, but I am the lone nurse in the district. The secretaries who staff the health rooms just don't have time to do more than jot down the basics, and the few volunteers I have wouldn't be able to access the computer records. The previous nurse tried to keep up with transferring info from the log to the computer system, but fell behind miserably.

How do you document your students' health room visits? If you do have individual student records, how do you keep it all organized (cards, binders, etc)? And, how do you keep track of your daily/monthly stats?

Any copies of forms (individual or monthly log) would be appreciated!

Thanks!!

[kidsnurse1969]

I found myself in a similar position when I began my current job. My goal this year is to become more compliant with the privacy laws. I am keeping an electronic sickroom log of students names, dates, time in/out, teacher sending and basic reason for the visit (first aid, illness assessment, medication, other). I keep this on an Excel spreadsheet so that I can more easily manipulate the data for tracking purposes. (I think this is allowed by HERPA/FERRPA.) So far it is working and fairly easy to keep up with.

The detailed portion of my documentation is much more tedious! I am keeping a traditional narrative note for each student that I see. I keep these in a large 3-ring binder. This part is killing me!

My district has plans for a new student management system which would computerize the whole thing. So the only thing that encourages me in this is that it will only be for one more year.

I, too, am curious to know how others manage their documentation.

[mamahuff]

I have used a paper log that i made up myself. It has lots of abbreviations and is pretty quick. I keep one on each student in a 3 ring binder. I go to 5 different buildings. One of the secretaries also use it as her quick log to write all the kids on. Then she also puts it in the computer. It works pretty well for both. If you give me your e-mail addresses I will send it to you if you would like for me to.

[michigooseBSN]

9 years ago we went to computerized documentation. Since we have a full time nurse in each school this is possible. For several years we used it primarily for demographics and immunization documentation but 5 or 6 years ago we went paper-free. That was scary but now it is second nature. It is so worthwhile. Each nurse has her own computer and it is easy to look up all sorts of thing. For instance; a running record of all healthroom visits for a given child or a list of all nonimmunized and suceptible students if we get a case of communicable disease like varicella in the building. Now I can't imagine how I could keep a finger on everything without it. When the servers go down it is an awful disruption. And yes, I do know how lucky we are to have such an up-to-date computerized system in my school district.

[ClinicCarrie]

In our county in GA the student (or the clinic assistant for the student) signs in on a paper log. Name, Grade, Reason for Visit, Time In. The rest of the log entry is for comments, temp, time out, fields to mark as sent home, return to class, talked to parent.

This data is then transferred into a computer system (during the shift and/or after clinic closes). The paper sheet also has counts at the bottom for several of the fields which we do manually per day, such as number of routine vs PRN meds were given, how many kids sent home, etc. The computer program wasn't designed to do those.

The parents can look at the log entries online if they are so inclined from their school's website. There is a "hidden comment" field if one wants to document extensively about an event that can't be seen online. The parent entry looks like the following:

Date:12/7/2007 Incident Description:MENSTRUATION PROBLEMS Comments:MENSTRUATION PROBLEMS End Date:- Visit Description:Routine Visit Visit Comments:supplies Time In:1:35PM Time Out:1:40PM Follow-up Date:-

[joy09]

We are in the process of learning a new computer system. With one nurse in the room and the computer in the office, it doesn't seem possible to enter all of the data. Our manual system is large index cards kept in recipe type boxes. We pull the card when the student comes in and document time, date, chief complaint, history, assessment, interventions, disposition. At the end of the day, a quick review of the cards yields our daily stats and we put that on a form to compile at the end of the month. Another way is to tally visits in the categories as they comes in and add those up and put into the report form at the end of the day. I would prefer the computer method, entering as I go along. If and when they give us computer access in the treatment room, we can try it.

[K8schoolnurse]

you are all making me feel so fortunate! I have a computer in my office and one in the Health Center. We have computerized documentation including Daily Logs, Daily medications, daily procedures, immunizations, health screening and incident reporting. It is very user friendly. This is my first year as a school nurse and even though I feel overwhelmed with immunizations and vision/hearing screenings that are due, I think I'm going to love this change of direction in my nursing career.

[RNCert2009]

I am currently in a district that could really use a computer based charting system. Does anyone have any ideas on the kinds of programs that you are using and / or the cost involved?

Thanks in Advance!

[michigooseBSN]

We use HealthMaster and have done so for 9 years. It is on our PCs.

[GRAMMYTAB]

Hi,

I just keep a daily log, I use a generic sheet and fill in the blanks. I keep them divided by the month in a notebook on my shelf. I am alone in the office so there are days that it piles up on me and I get behind, but I try to document every little thing I do. This also helps me to see a pattern of our "frequent flyers" and which teachers are just letting the kids come because they dont' want to mess with them!!

Tabitha:banghead:

[pugmomrn]

Thanks all--

We do have Skyward-- the way it is set up, it would work well in a school clinic setting or if there was one of me in each health room-- could track office visits, med administration, etc.

But, as I said in the original post, my predecessor had tried to transcribe all of the health room logs into the system at the end of the day, and fell behind miserably. Unfortunately, since we are staffed by secretaries and volunteers, the old fashioned pen and paper system will have to do for now.

I'm thinking of changing our emergency cards from half to full sheet card stock, sticking them into big binders, and using the backside to log visits. Again, hard to track stats and daily HR activity without double charting. *sigh*

[PvtSchlNurse]

I don't have a computer system (heavy sigh, in my dreams....) and use paper. We have a sign in sheet that lists time in/teacher/student/complaint code/time out/disposition. We came up with a list of complaint codes so no one knows why anyone is being seen if it is glanced at. It helps with stats too.

I have a large three ring binder (yep, giant sized) and keep all the Clinic Log sheets in that, every student has one. It is put in their file at the end of the school year. I chart as I go. I also have a check off sheet that is a notification to the parents of the visit too. If you send me your email address I'd be glad to share the forms with you.