Confronted about charting at patient's school

Specialties Private Duty

Published

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....)

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

The communication in the classroom is for the school personnel to document not the nurse. Even if you document communication when you are home 1:1.

Deferring the parents to contact school personnel regarding activity at school is a smart move. You do not want to be in the middle; I've seen first hand this go very badly for a beloved nurse especially if there is room for misinterpretation

Up Vote Up Vote ×
Specializes in Critical Care.
...

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!

This is what I could see the teacher and school taking issue with:

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.

It does seem pretty benign, but there isn't really any necessity to provide the parents with quoted dialogue from school to express how effective the child's communication device is helping with communication. And how well the child is doing at paying attention, engaging the content, etc is the teacher's domain.

Up Vote Up Vote ×

As a parent, I get that control is an issue. AND that a communication device that I would spend a great deal of hours working with my child on is being used to the child's advantage.

Communication appropriate and understandable would be a generalization of this part of the day.

I am assuming that there's other professional's involved, as in a speech therapist, OT....and that would be their domain to discuss an IEP or plan of care with the parents. And their domain to assess and communicate said assessment to parents. As a nurse, you are not a speech/language pathologist nor a occupational therapist. Both of which I would assume are part of the student's IEP. Which needs to be followed to the letter (in a perfect world, but story for another thread).

Bottom line--you are reporting off on things that are not within your scope. If the parents want to know about communication, they need to regularly conference with speech/OT. There are parts of how one learns to communicate which translates into reading and writing and many other aspects of a teacher's responsibility in educating. IEP's are strict and legally binding. Yes, a nurse you can say that the child is communicating needs effectively. You can at a care conference talk about how you would like the child to be able to communicate needs that he may not be. (ie:I am hungry, I hurt....).

Between an IEP, other disciplines, as well as the insurance reimbursement for the machine needing more than likely a speech pathologist and/or occupational therapist assessment (all of those I's to dot and T's to cross) I would not put your liability at risk by blurring those lines.

Up Vote Up Vote ×
Specializes in ED, psych.

The school isn't out of line at all. Their approach isn't cuddly and very team-like, but ... As Jadelpn stated, you are reporting off on things that are not within your scope, and this is where you need to be very careful. It can seem like no big deal to state that your client can become disengaged and doesn't answer questions ... but these can actually be IEP objectives that you're unknowingly stating your subjective observations on.

For example, I had a student with autism (I used to be a teacher) who had a goal of at least 80% of on-task behavior within the classroom environment (operationally defined as in seat with hands on desk, with the absence of self-stimulatory behavior blah blah blah ... you get the gist) on his IEP. Now, I was pretty dang frustrated when the parents contacted me because they kept receiving notes from the OT stating the child is frequently off task, etc. After speaking with the OT, despite the fact that the operational definition of "off-task" was clearly defined, well established, and data was being collected using a momentary time sampling technique, her idea of off-task was that the child's eyes were darting around the room despite the fact that the child was still completing their homework while in their seat (which is huge, considering the child was never in their seat in the beginning of the year). The kid was never going to be on task under her definition.

So, you can inadvertently be adding to unnecessary confusion to the child's progress.

Now, as this child's teacher, I would go about this differently then how they are going about it with you, in regards to not being "allowed" to give report regarding what happens at school. That's incorrect, and not cool. Not very team like. I hope for the child's sake that this can be resolved ASAP (on both sides) so he can have the team approach he needs.

Up Vote Up Vote ×

I think you made a mistake by suggesting the parents speak with the school directly about this issue. I think you should have gone straight to your employer and clarified policy, and then either follow it or have your manager speak with the school. It will be really sad for this child if you're removed from his case because of the way this was handled.

I also don't understand why you couldn't have just given the parents a verbal summary with some of the details that you recalled. A daily diary of things that are not part of your plan of care seems like you are being complicit in the parents' micromanagement.

Up Vote Up Vote ×

Thanks everyone for all the responses. I definitely did not intend to be doing anything out of my scope, and I am going to tread lightly now.

To clarify, I don't document communication or any school activities in my nursing notes, I would just write down phrases the patient speaks (sometimes he puts together a full sentence or phrase) to relay to the parents when we get home and they ask me what he said. I do not keep a 'diary,' only note specific things he says using his AAC device, on my brain, which gets destroyed at the end of my shift. When we get home I can tell the parents exactly what words he strung together with his device.

From now on, the parents can discuss these specifics with his teacher or one-on-one aide at the school. I will stick to just writing my nursing notes, and if I can't give a specific enough report from what I can recall, then they will have to discuss that with the teacher/school. Honestly, I was just trying to be thorough and write things down so I don't forget (this is always my habit) It was never my intention to step on any toes, and I think that the school could have approached this in a much more constructive fashion, to facilitate a team approach, as one poster said.

This is not the first 'control' type issue at this school. Another nurse had issues when a PT complained about her disconnecting the patients pulse ox during a transfer, and administering Tylenol for discomfort. This PT also demanded that she be the only one allowed to transfer the patient at school. (The PT 'wasn't comfortable' with the nurse doing these things)

That said, I am now very aware of the line I must not cross when it comes to reporting anything out of my a scope. And I definitely don't want to get drawn into an unnecessary power struggle that will do no good for anyone, especially the patient.

Up Vote Up Vote ×
Specializes in Nephrology, Cardiology, ER, ICU.

Moved to PDN nursing

Up Vote Up Vote ×

emmylue do you work in the suburbs of chicago

Up Vote Up Vote ×
emmylue do you work in the suburbs of chicago

tonih79 I work in the city, not the suburbs... Why?

Up Vote Up Vote ×
Specializes in Peds(PICU, NICU float), PDN, ICU.

Don't get in the middle of it. The nurse always gets thrown under the bus. Let the supervisor handle it. Keep doing your job. Your documentation covers you, so keep documenting as usual. You may lose the case, but at least you won't be burned. They will find a nurse that will do what the school wants (even though its wrong).

Up Vote Up Vote ×

Hi there!,

I just want to say that you rock!! I am a parent to a nonverbal child as well. He does not require nursing, but we have had the run around with getting information relating to the classroom. Ask for their policy in writing, chances are they don't have one. Secondly, have the parents get up their asses about the lack of communication. Have them call an IEP meeting and then provide the teacher and team with a sheet that the teacher must fill out every day (i'm happy to provide an example of one :) It sounds as if the school has something to be worried about. I had this issue at the beginning of the school year, they wouldn't let his 1:1 speak to me. We switched schools and I have no problems now.

Up Vote Up Vote ×
Hi there!,

I just want to say that you rock!! I am a parent to a nonverbal child as well. He does not require nursing, but we have had the run around with getting information relating to the classroom. Ask for their policy in writing, chances are they don't have one. Secondly, have the parents get up their asses about the lack of communication. Have them call an IEP meeting and then provide the teacher and team with a sheet that the teacher must fill out every day (i'm happy to provide an example of one :) It sounds as if the school has something to be worried about. I had this issue at the beginning of the school year, they wouldn't let his 1:1 speak to me. We switched schools and I have no problems now.

Bridge08t... Thank you for your words! It is so great to hear from a parent like you! I really want to advocate for my patient. He was my very first pediatric patient (since he was about 11 months) and I've been with him for so long, watching him grow, and when he began to use this AAC device, and began verbalizing his thoughts and wants and ideas, it was sort of like meeting him again for the first time. So when we are in the classroom, I really want to see him maximize every opportunity. He is so intelligent, and I know he will face so much adversity and be judged unfairly by so many people in his life... I don't want him to have to deal with these issues any sooner than he has to, especially when he is just starting out in his educational career. Fortunately, he has a really amazing one on one aide this year, and she has made a huge difference.

I would really love to see the form you mentioned for the teacher to fill out. It may not be appropriate at this time, but I could see it being useful in the future, for him and others, I'm sure. If you don't mind, can you receive a PM?

Thanks again!

Up Vote Up Vote ×
+ Add a Comment