bugging me

[peaceful nurse, RN]

I am an RN/ Health advocate for a Early Head Start Child care setting. Part of my job is to obtain physicals from the families and enter them into the system that we use. the form is pretty self explanatory and allows the physician to fill in BP, HT, WT, Appt Date, BMi, Lead level, hgb, vision, hearing and immunization. Then the physician signs the bottom.. I may be anal but if they leave something blank then they did not do it or they did not write it down. This is a new job so I am learning how to use the system and that children under a certain ages vision and hearing is subjective. However there is nothing written on the physician form signed by the doctor. however when I put in the our program I can put that they passed...umm there is no place where the doctor actually said that and I did not perform any part of that physical.. too anal, right? I just needed to get this off my chest it has been bugging since. I do realize that our system is nothing like nursing but it seems right that everything should match. Our records may not be legal documents but they should still be accurate. Nursing philosophies are ingrained

[Windchaser22]

I'm the same way. If it's bank, it didn't happen.

[peaceful nurse, RN]

Thank you.. I realize they are not nurses.. but there is a huge principle.

[peaceful nurse, RN]

so I was told by a worker of one pediatric doctors that the dr does not do hearing and vision as part of her exam for children under four. I was told by my manager to look up the kids that did not have a hearing and vision done.. I found four... when I showed my manger her response was oh they are just subjective and we can put they pass.. however there has got be better way.. I can't put that as nurse on the exam form if the doctor does not... if I have not assessed i can't even put subjective.. please help...all my children are under 3

[SnowyJ, RN]

Can't document pass/fail unless it is documented as such by a provider.

[abc123RN]

I worked for Head Start years ago, no EHS so not real sure on under 3 screenings but we did our own screenings. I, along with FSW staff, were trained for vision, hearing and speech screenings. I'm sure you have accessed this but I got a lot of help from this website, Health Services Management. The program I worked for was in the process of setting up EHS when I left to follow another dream. Good luck, HS/EHS is a whole other world, unlike anything I have ever done before.

[peaceful nurse, RN]

Trust me I am on the same page as can't/ won't document unless the provider does... that is ingrained. I can assess myself in the center but some are home-based and document separately from the doctors exam and write it was subjective per mom and Home visitor.