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?