School Nurse Documentation

  1. Curious how other school district nurses document things? We have a computer program to input med allergies, meds, vision and hearing screenings, etc, but it is not overwrite protected and there is not a place for daily/weekly/prn documentation. There is a small space on their cumulative file and I notice that previous nurses have used that space for info such as IEP reports completed. But where do I document daily conversations/needs I deal with so others (like my health assistants and the office staff know what is going on)? Of course, if there is something I email/call them, but it seems like there should be a place to document what I am doing for communication and legality. Of course I keep a binder that contains all of my schools and each school has a tab where I can keep notes relating to students I am dealing with. But I am getting frustrated trying to keep it all straight and keep those who need to know in the loop. How do you all do it? Everybody tells me I am organized, but I do not feel like it! I go to a different school each day and feel like I have to keep everything in my head, whereas my previous clinic job, we documented everything. So how do you document?
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    About elprup

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  3. by   NutmeggeRN
    I use MMS and one of its downfalls is, that it too, is not overwright protected. I use the daily log and can add codes to it. One condition is OTHER and it covers a whole lot of stuff!. I use the notes section to detail conversations or what was done.
  4. by   Flare
    i use healthmaster. it's overwrite protected. I really like the program. When i came to this district it was one of my requests
  5. by   elprup
    Are MMS and Healthmaster different software then what the teachers/administrators use for grades/attendance/etc? Everybody in my district uses one software, that seems to be great for admin and teachers, but there is no place for nurses or health assistants to document. We literally use binder paper or keep it in our heads - which is making me uncomfortable. But everybody keeps telling me, that is the way it has always been done. And since I just started I do not want to make waves......
  6. by   Flare
    the teachers here use on course - i use that too to put health alerts for staff, to check attendance, to look up contacts, ect... it has a health module, but the healthmaster program is better. overwrite protected, you can make templates for quick charting, keeps the list of items pending, so i know where i stand with all my meds. Don't be afraid to make a few waves, thay may not know that there is something out there that will benefit you, the students, and ultimately them. In the end you are covering their rearend.
  7. by   NutmeggeRN
    MMS is Modular Management System has grades, biographical, attendance. Only myself, IT and 1 person in guidance can access health info and she only has rights to immunizations.
  8. by   elprup
    Thank you.