Any way to make this quicker??

bergren · Aug 25, 2010

"That's exactly what the PreK nurse was told to put,...." By whom? Nurses are not told what to chart. Nurses chart what they see, hear, smell, and palpate . The type of rote, repetitive charting you describe would be a huge red flag if the child ever had a complication. It does not reflect assessment or critical observation or evaluation of the nursing care.

"Any way to make this quicker??" What do you mean?

"Feeding administered without difficulty" What does that mean? - you should chart what "is" as opposed to what is not. What are you feeding the child? How is the feeding administered? by gravity? By pump? over how long? Are you supposed to check for residual? If yes, how much was there and what did it look like. Was the child comfortable? How could you tell? Do you vent, flush? ? What is child's position during and after feeding? This can be put on a check list / grid - does not need to be long hand each time.

At the first feeding, chart what the site looks like. Do you do site care? If so, that should be charted?

Here is a link to a fundamentals text. It includes what to document: Best practices: evidence-based ... - Google Books

I do presentations on school health office documentation - some dos and don'ts:

Do's

* Make sure your documentation reflects the nursing process - assess, plan, implement and evaluate

* Write legibly, or even better, chart electronically

* Record every communications with child, provider, parent and teachers, including time, content & response.

* when delegating, chart the training, your observations / evaluation that the person can perform that task proficiently and has the knowledge to do the care, and when they need to contact you.

* Cover the care that the care plan or IEP said you were to provide. School districts are being asked to give back Medicaid money because school nurses have not documented the care in the IEPs that are reimbursed with federal funds.

* Do keep a daily log of name, time in, time out, disposition (back to class or sent home) (See more about daily log in Don'ts)

* Do keep files locked and block information on desk / screen from inquiring minds

Don'ts

* Don't document a child's or parent's complaint without charting what you did about it and your evaluation of the child's / parent's response.

* Don't use non standard abbreviations

* Don't write imprecise descriptions, "normal", "fine" "rash"

* Don't write "seems, "appears", it is or it is not.

* Write a rationale for any ommissions of care or when you stray from the procedure or policy

* Always chart if the child was sent home or back to class

* Never chart that an incident report was filed

* Don't chart any health information on a daily log unless it is destroyed after transcription to the chart.

LACA, BSN, LPN, RN · Aug 25, 2010

My main question is does all of this have to be long hand charting each time. I will make up some sort of checklist for each day's feeding and go off that.

She's fed by pump, that's also at the top of the sheet. I was concerned because the PreK nurse didn't seem to chart enough information, but with her getting three feedings a day, it's near impossible to chart every little thing. But if I can use a checklist, that will make it much easier.

I've never done a tube feeding in a school setting, so it's definitely something new for me. I will try the checklist method and see how that works.

Jolie, BSN · Aug 25, 2010

I would also caution you to make sure that the school district approves of any charting form you devise. We have had problems in the past with staff members creating and using charting forms for individual students with unique needs. These were non-standard forms that often lacked certain necessary information, and were not reviewed by the district's legal consultant. While I understand the benefit of having a user-friendly flow sheet for tube feedings, you may want to check and see if such a form already exists and is being used in another building or with another child, or get an "OK" from your district's administration or lawyer that the form you devise is acceptable.

LACA, BSN, LPN, RN · Aug 25, 2010

The sheet that the nurse that had her before gave me was a very generic "procedure log sheet" that the district uses. It has absolutely no information, other than what we fill in. From what I've been told, no specific sheet for tube feedings exist (tube feeds are few and far between in our smallish district). There's not even a set way of charting things for us. Some use computer charting, some use notecards, some use paper charting in a folder, some use paper charting in a binder, etc. We all have log books that we use for very basic logging. From what I've been told, our state doesn't govern school nurses as far as auditing records or anything like that, so whatever we write down is just for our records. I may be completely off on all this, but I'm trying to get everything figured out and make sure that I'm not doing something that's going to cause me problems. I don't want to come across as an idiot, I just want to make sure that I'm correct on what I'm doing. I know the basics of charting, but I've talked with other nurses in our district and was told that since the state doesn't govern us, as long as we have basic information, we are fine. Does this sound right?

bergren · Aug 25, 2010

What state are you in? Is there a state school nurse consultant? Members | NASSNC Does your state school nurse association provide a listserv? http://www.nasn.org/Default.aspx?tabid=60

The state "governs" all nurses through the nurse practice act and as professionals, we are expected to meet the standards of care. Some nurse practice acts are very specific in what they expect: Nurse Practice Acts So in a court, your care and documentation would be compared to the nurse practice act, the school nurse standards of practice IMPak - Product Information - S001 - School Nursing Scope and Standards of Practice and what a "prudent, reasonable" nurse would do.

Does your district have a school nurse supervisor? Nurses meetings? It would be important for all of you to protect your licenses to suggest minimum standard documentation.

LACA, BSN, LPN, RN · Aug 25, 2010

I'm in TN. I can't find anything specific online pertaining to the laws regarding school nurses in TN. I'm not a member of any of the school nurse associations because they are only open to RNs and I'm an LPN. We have a nurse supervisor in our county and we meet once yearly. We document basically the same things, just in different ways.

bergren · Aug 25, 2010

The Tennessee Association from the link TN Assoc. of School Nurses does not bar LPNs. You would be an associate member. Plus they have their own Tennessee listserv that would help with practice questions like this. And the fall conference specifically asks if a LPN RN etc http://www.tnschoolnurses.com/Events/TASN_Fall_2010_Conference.pdf

LACA, BSN, LPN, RN · Aug 25, 2010

The Tennessee Association from the link TN Assoc. of School Nurses does not bar LPNs. You would be an associate member. Plus they have their own Tennessee listserv that would help with practice questions like this. And the fall conference specifically asks if a LPN RN etc http://www.tnschoolnurses.com/Events/TASN_Fall_2010_Conference.pdf

But according to the TN Association of SN, you have to join through the NASN and it says "N/A" for Associate members in TN....I'm confused.

bergren · Aug 25, 2010

I called NASN's toll free number: 1-866-627-6767

You are right, I had the term wrong. In TN, the LPN would be a "member at large". There are a lot of benefits, 2 journals, listservs, Free CE, discounts on publications, etc etc - I do suggest joining