School Nurse Documentation

  1. New school nurse here!

    I cannot locate specifics on documentation for my state or district so I thought I would reach out through here before contacting a colleague in my district. I received zero training or orientation, as the prior school nurse only gave 1 week notice before leaving. But she kept a daily log sheet for each kid that came into the nurse's office and I was told she would entered information into the online school system called Sycamore.

    1. What is the purpose of the daily log sheet besides to catch trends? I can't see how it would be a legal document as any personnel writes in this book and no one signs their name to it.

    2. Does every bandaid and icepack visit warrant a legal documentation in their official health record?

    I want to ensure I am documenting the correct way. Going from acute care for the last 5 years to the school setting is a huge change up, but I know I will love it once I get my bearings! Any advice would be appreciated!

    Thanks!
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  2. 20 Comments

  3. by   moreoreo
    I document every injury I see, even if my only intervention is cleaning and applying a bandaid (or even no intervention at all), in case someone calls and asks if so-and-so came in to see me about whatever body part. I can confidently state whether I saw them, what I saw, and what I did. There is no way I would remember otherwise. It also helps me quickly identify students who are coming in too often.

    I also keep a covered daily visit log with just in/out times and where they ended up (class, home) which helps me to identify at a glance whether a student came in on a given day. Have to have this bc we don't have a computer charting system.

    Paper charting is slow, tedious, and I don't know how well it would hold up in court but I'd always rather have too much detail than too little!
  4. by   aprilmoss
    I figured a daily log was just a cross check for the per patient record, Confirm whether little Jimmy was in the office on Tuesday as well as Wednesday.

    I do periodically generate some statistics (how many kids I see a week, etc...) from the daily logs.

    I suppose if the per-student records were on a computer and could be searched I'd not need the dailys.
  5. by   Farawyn
    I use eSchools. And I document everything.
  6. by   Jen-Elizabeth
    Quote from Farawyn
    I use eSchools. And I document everything.
    I use SchoolBrains (specific to MA, I think) and I also document everything. Even when I give out a bandaid. But I have created drop down shortcuts in my software to make it easier.

    This is helpful for trends, legal stuff, and also basic traffic tracking. My boss loves data and since my boss isn't a nurse, that data is something he does understand and helps me a lot when communicating my office needs.
  7. by   Farawyn
    Quote from Jen-Elizabeth
    I use SchoolBrains (specific to MA, I think) and I also document everything. Even when I give out a bandaid. But I have created drop down shortcuts in my software to make it easier.

    This is helpful for trends, legal stuff, and also basic traffic tracking. My boss loves data and since my boss isn't a nurse, that data is something he does understand and helps me a lot when communicating my office needs.
    The one time you don't document? That will be the time there's a alwsuit aginast the school and they ask for a nurse's note.
  8. by   moreoreo
    Quote from Farawyn
    The one time you don't document? That will be the time there's a alwsuit aginast the school and they ask for a nurse's note.
    That's the mindset I document with too. Even if it's Vaseline for chapped lips, this way I can point at my notes and say "these are the only visits this student ever made to the health office this year."
  9. by   SullyRN
    I have a book that I jot visits down quickly in, sometimes I get 3 students at once, so there isn't time to chart them in the computer as they come through. I will quickly write down a name and a short description that will help jog my memory of the visit. (J. Doe, s/a, 99.2 or K. Doe, R ankle)

    When I get time I document in the computer, but I document on every student that walks into my office. Even if I did nothing for them. Kiddo comes up waning me to pull a tooth, I chart "student asked for nurse to pull tooth, informed student that nurse does not pull teeth, blah, blah"

    This helps for the parents whose snowflake tells them they came to see the nurse and I did nothing for them. I can tell them with certainty that A.)I did not see your student today, or B.)I did see your student, they rested without vomiting, I gave them water and a mint and they told me they were fine to return to class.
  10. by   AdobeRN
    We use Eschool - I document everything or at least try to, we do not use paper documentation. I will miss a bandaid or ice pack here and there when I am really busy. Majority of the time it is clicking on a drop down menu of items, so it doesn't take that much time. Occasionally I will write a little narrative but most of the time it is very brief.
  11. by   WineRN
    We have a computer program (SNAP) where I chart everything except bathroom visits (that would be most of my day if i did that).

    On very very busy days, I have a paper log sheet that I use to jot down the students name, main problem, and time in and out. Sometimes I just can't be at because of a rush of skinned knees and possible concussions and reported vomiting little ones all marching in at the same time
  12. by   Amethya
    I have completely different instructions, as such because I'm just a CMA, not an RN or LVN. I call parents and document EVERYTHING, doesn't matter what is for. If it's a small bandaid, I don't say anything, but it's something like a bleeding cut or such, I do call parents. I would say maybe this could be safest route for you.
  13. by   kidzcare
    Quote from moreoreo
    I document every injury I see, even if my only intervention is cleaning and applying a bandaid (or even no intervention at all), in case someone calls and asks if so-and-so came in to see me about whatever body part. I can confidently state whether I saw them, what I saw, and what I did. There is no way I would remember otherwise. It also helps me quickly identify students who are coming in too often.
    Assessment is an intervention
  14. by   moreoreo
    Quote from kidzcare
    Assessment is an intervention
    A much needed reminder in my elementary world where only ice packs count as "something"

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