Confronted about charting at patient's school

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I work private duty, for an agency, and have gone to school with several patients, and have never had an experience like this before. I attend preschool with my 5 year old patient who is trached and vented, at a school that has had many students with their own nurses before. My patient has a one-on-one aide at the school who works with him, and I manage his other needs (suctioning, managing the vent, gtube feedings, medications, transfers, etc).

This student uses a dynavox-type device for communication, at home and school, and is still learning how to communicate. He is completely nonverbal, but cognitively intact and very intelligent. His parents work with him, very diligently, for hours each day, so that he can communicate effectively. When we get back from school, his parents want to know how he did.... Sometimes he gets distracted, doesn't answer questions, becomes disengaged,etc. so I make brief notes for my report to the parents about exactly what he said at school, so that they know how he is communicating and interacting with his peers and the teachers/aides. I also do some of my narrative nursing notes and other documentation (vent checks, 24 hour flowsheet) at school, as I am required to write separate notes for the hours he is in school. I keep my notes inside of a storage-type clipboard, always in my possession, so there is no risk of accidental HIPAA violation.

I was confronted by his teacher and then his principal. They told me that I am not allowed to give the parents any report regarding what happens at school. I explained that I am not evaluating the teacher or making any kind of educational assessment, just reporting exactly what happened during the school day and what the student said using his assistive communication device. They continue to maintain that I am not to discuss what happened at school with the parents, that is the teachers job. (That's fine, but the teacher does not communicate these things to the parents, and of course they ask me, who was there by his side all day, what happened at school).

Yesterday, the teacher approached me again because she saw me "writing," and told me that I need to be sure I am only writing 'nursing things' down.

I have been to school with several patients, and I have charted at school. Again, I am not charting about the lessons taught, or the content of the teaching, or anything like that. Only my regular documentation, and exactly what my patient says using his communication device. I have never heard of anything like this before! Did I miss something? Can the school dictate what I am allowed to document in my nursing notes and what I report to the parents? Again, it is not just the teacher... the principal of the school told me the same thing.

I would appreciate any advice on this... It makes me extremely uncomfortable, and I wanted to ask some of you more experienced nurses and school nurses if there is something I missed.

(I tried to correct my paragraphs, and they just aren't showing up after I save my post. Please forgive....)

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Specializes in Dialysis.

I would think not. That is part of your job. And the parents have a right to know about their child's health status, which would include his communication. I would address this with your agency, and have the parents take it up with the school board/corporation.

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Specializes in SICU, trauma, neuro.

Have you gotten your agency involved? I think the opposite of the principal: he/she has no need to know about your professional communication with your clients. You might get better advice from experience on the home care/PDN forum... but as a parent, yes I would expect to know what happened with my child from his nurse's perspective.

You're under your agency's chain of command, not the school district's, correct? That's why I would involve them. You follow your agency's guidelines and are ultimately accountable to the child and parents. If they want info about their child that you have, you need to give it to them. I don't see that as the principal's concern.

Frankly if I were the parents, I would personally advise the principal that the nurse and I would be discussing any information about my child that I wish, and that he/she will be part of that communication when I choose.

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As said above it it probably best to contact your supervisor about the issue. I have had issues in school nursing before, not the same but similar, and it's better if you speak to them before the principal does. I've had them call and complain about me for just doing my job. Also talk to the parents, if you tell them what the principal and teacher it might clear things up. But make sure to get in contact with your supervisor.

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Thank you for the responses... I did discuss it with my patients parents, and they are going to speak to the principal today. They are, of course, of the opinion that they have he right to know what happens at school. I have a scheduled call with my supervisor this afternoon, and will discuss it with her then.

I know that the world of PDN can be very different animal, but I have never had my professionalism questioned like this. I really appreciate the responses, and I will be following up this afternoon.

It shocked me that the school wants to 'manage' what the nurses report and document. I mean, if they were to be in regular communication with the parents, they could relay all the same information to them.

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I wish you luck in sorting everything out! Sometimes people just want to micromanage everything. Teachers and school staff shouldn't have a say in what you write in your notes especially if parents request the information.

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Specializes in Medsurg/ICU, Mental Health, Home Health.

What's going on at this school...something they don't want parents knowing?

Weird.

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Specializes in Ortho.

School is out of line

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Tell them you didn't go to school to be a teacher, and in turn they didn't go to school to be a nurse. You aren't telling them how to do their job, so you'd truly appreciate if they'd stop telling you how to do yours.

also next time if a teacher instructs you to write down only nursing things, tell them "I'll write down whatever I feel is relevant to my patients care, please continue with your teacher things."

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Specializes in Critical Care.

I have to agree with the teacher and school on this one. You're completely free to tell the parents how the student did at school from a health perspective, but you should defer questions about his school performance to the teacher, even if it's you they are asking. It doesn't help if parents get potentially conflicting information about his school performance, just like it would be frustrating for you if the teacher was reporting things to the parents about the child's health that didn't agree with your assessments.

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I do not believe that there is anything for the school to worry about. I know I am not doing anything wrong, and I don't believe they are either (at least from what I see... I am at his side the entire school day, but I do not see what happens behind the scenes). That said, we live in a very litigious society, And one of my first thoughts was that they were concerned I was giving some kind of incorrect or 'biased' info that could be viewed in a negative light by parents. I have dealt with many a family that was looking for something wrong. From my perspective, this is is not the case with this family. But I do not know where the school is coming from; this may be their concern. And I am now sensitive to that.

However, I am ONLY discussing the exact phrases/response the patient gives his AAC device. And on a non-school day, when I am home with him for 10-12 hours, he communicates with me in the same device. And when mom and dad get he from work, they (of course) want to know how he communicated. I would of course tell them. They are also more than welcome to read the narrative nursing notes that are kept in the home until we mail them out each week.

MunoRN, I appreciate what you are saying, and this is my concern. I do not intend to be giving any report on any "educational issues" (as the teacher says). I have worked with this patient since he was 11 months old, have watched his ability to interact and communicate verbally and nonverbally grow, and I feel perfectly capable of giving a report on how he communicates in school (because I, and his other nurses, and his family, teachers, etc) use it to communicate with him on a daily basis. However, I have no intention of trying to how his evaluate his teachers, aides, or therapists interact with him. That is not my place, and I am not qualified to do so.

My only goal is to let the parents know what happened in school. I don't want to make things difficult for myself or anyone else, That said, I have let the parents know that they need to communicate with his teachers and aides about the daily progress made at school, because I am not going to be put in the middle. They are welcome to discuss (what they may perceive as ) poor or lacking communication about daily interactions, etc with his teachers and the principal.

Thanks again for all the input. Much appreciated!

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Specializes in Complex pedi to LTC/SA & now a manager.

We do not document school activities. If in PT we don't document activity just tolerance (client working with PT Awake alert NAD, respirations unlabored....

School/classroom issues are not to be communicated by the nurse. Only teacher/admin to parents. Especially if another student is involved, unless the student's health at risk . Classroom communication is school domain not nursing.

If he sprinted off the vent without issues during PT that's nursing. Desaturates in the stander--nursing report. Liquid BMs or 5 wet diapers---nursing.

Answered 3/4 comprehension questions correctly it's education not nursing.

You should not be documenting anything other than nursing assessments and skilled nursing care. Amount of communication during school is a school domain not a skilled nursing domain. If audited by public school district for reimbursement and your notes are focusing on school domain issues it may not be paid.

My agency has very specific guidelines for transporting students and accompanying to school. In my agency, the school would be correct in this scenario. Professional barriers are made clear. Policy is very specific and I think you should have contacted your clinical supervisor immediately once spoken to by administration

You are risking the school requesting that you are removed from the case and not be permitted to return to the classroom.

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