Confronted about charting at patient's school

[doodlebuttRN]

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....)

[nursel56]

I'm just going to quote parts of this that caught my attention in this situation. I would be upset about it, too.

. . .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.

That sounds like an uninformed and paranoid thing to say to me, so I would look askance at their motives and knowledge base right from the start.

Unless someone is peering over your shoulder, how would they know the difference between a narrative note and a vent flow sheet? The flow sheet checks must occur at the intervals indicated or it is below standard of care, so I would hold my ground on that one.

Are their feathers ruffled because to them you appear to be writing about things at the time they are happening? In that case maybe a more unobtrusive appearing style would allay their fears. I love industrial clipboards, but they tend to be symbolic of someone checking up on someone else, whether it's true or not.

I have never heard of anything like this before! Did I miss something? Can the school dictate what am allowed to document in my nursing notes and what I report to the parents?

No, and I would be interested if it's a HIPAA violation for them to discuss the content of your nurse's notes, and certainly to micromanage the content of the notes.

[Kooky Korky, BSN, RN]

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.

Why would nurse's notes be audited by school officials for reimbursement?

[QuietRiot]

The school is F.O.S

[JustBeachyNurse, LPN]

Why would nurse's notes be audited by school officials for reimbursement?

The public school district is paying the agency for the nurse to accompany the student in school to provide a free appropriate public education. They have the right to audit nurses notes as they are the payor for the services. Private insurance and Medicaid have no obligation to pay for nurses to accompany a child to school the school district does per federal law.

Since the public school district is paying they have the right to audit the notes.

As far as HIPAA it doesn't apply to the classroom teacher or principal looking at notes since insurance is not billed the public school district is billed for services. Therefore FERPA applies and depending on the scenario it's often a permitted disclosure

[middleagednurse]

You are employed by the agency, not the school. The school can't tell you how to do your job, anymore than you can tell the teacher how to do her job. The DON at your agency needs to talk to the principal and teacher and tell them to mind their own business.

[middleagednurse]

Please ignore the above comment because I may be wrong. I tried to delete the comment but I can't.

[JustBeachyNurse, LPN]

This should have been deferred to your clinical supervisor the first time you were confronted. Your agency most likely has a policy. While your employer is the agency the agency is contracted by the public school district to provide 1:1 nursing services in the school.

The school administration absolutely has the right to ask to have you removed from the case and not return to the school setting. Documenting student communication in school is not a nursing task. Providing a form for the parents to have the school staff to complete is most definitely crossing professional boundaries and can lead to you being pulled from the case. You can be too helpful and jeopardize your roll.

If you were documenting educational and school therapeutic services you are outside of your roll. And I have seen nurses document extensively on teacher activities and therapist interventions and insufficiently on skilled nursing.

The public school district audited charts for payment and tried to discontinue skilled nursing due to no documented need and replace with a 1:1 paraprofessional. The nurse was removed from the case. The parents were very upset. The nurse is no longer welcome at this school. Yes this is an extreme example. But PDN at home and school is very different than facility nursing.

[JustBeachyNurse, LPN]

You are employed by the agency, not the school. The school can't tell you how to do your job, anymore than you can tell the teacher how to do her job. The DON at your agency needs to talk to the principal and teacher and tell them to mind their own business.

Not exactly. The school district pays the agency to provide one to one skilled nursing to ensure a child receives a free and appropriate public education. Quite often the principal is the agent for the district and can inquire and intervene on behalf of the district.

If the nurse is overstepping professional boundaries by acting as a communication liaison (it should be school/teacher to parent not school > PD nurse > parent) then there is an issue whether the nurse is not clear on her role or the school is not effectively/efficiently communicating home. If the parents want a daily diary of the words/phrases/sentences/requests communicated via AC by the student the 1:1 paraprofessional could be tasked to provide such documentation daily to the parents (a common duty assigned to 1:1 aides)

The agency supervisor should have been called at first confrontation to review agency policy with the nurse and intervene with the school to preserve school/agency relations. This is one of the jobs of the agency clinical nurse supervisor.

[doodlebuttRN]

Again, as I stated, I was not documenting anything about education or school activities in my nursing notes, and I was not "keeping a diary." I made brief notations of statements the patient verbalized using his AAC device on a separate sheet of paper (shredded at end of shift) so I could answer the parents accurately when they asked me what words he strung together to make phrases or sentences in school using his device. I have never and would never try to evaluate school activities, or school curriculum.

JBN, I am really focusing on making sure I do not overstep my boundaries; I appreciate your point about 'being too helpful,' and getting in trouble that way. You are absolutely correct, and thank you for making that point. I have no further intention of trying to facilitate communication between the school and parents. There is actually a 'communication log' that the teacher is supposed to fill out each day for the parents, but it is left blank most days. I have directed them to contact the teacher if they need anything specific about the school day.

I am no longer allowing myself to be put in this position. I have told the parents that I will happily report The patients condition in school, and but they will have to contact the school/teacher for anything specific to the content of the school day.

As as for my nursing documentation, it always has been and will continue to be entirely focused on the skilled nursing care provided.

[JustBeachyNurse, LPN]

Again, as I stated, I was not documenting anything about education or school activities in my nursing notes, and I was not "keeping a diary." I made brief notations of statements the patient verbalized using his AAC device on a separate sheet of paper (shredded at end of shift) so I could answer the parents accurately when they asked me what words he strung together to make phrases or sentences in school using his device. I have never and would never try to evaluate school activities, or school curriculum.

JBN, I am really focusing on making sure I do not overstep my boundaries; I appreciate your point about 'being too helpful,' and getting in trouble that way. You are absolutely correct, and thank you for making that point. I have no further intention of trying to facilitate communication between the school and parents. There is actually a 'communication log' that the teacher is supposed to fill out each day for the parents, but it is left blank most days. I have directed them to contact the teacher if they need anything specific about the school day.

I am no longer allowing myself to be put in this position. I have told the parents that I will happily report The patients condition in school, and but they will have to contact the school/teacher for anything specific to the content of the school day.

As as for my nursing documentation, it always has been and will continue to be entirely focused on the skilled nursing care provided.

Good for you. Please let your supervisor know of the school concerns. There may have been issues with other nurses that you are unaware of that makes the school hypervigilant and not necessarily about you or your client. Just take care with which observations you document it's easy to write too much. Example:

Client working 1:1 with classroom staff awake, respirations unlabored, HR 120, SpO2 99%. NAD. Secured in activity chair with safety straps (skilled Nursing)

vs

Client working 1:1 with Ms. Dana hand-over hand to utilize switch to identify colors & shapes with 4/5 and 5/5 accuracy. Identified 15/22 letters stated verbally with minimal prompts using a field of 6 on AAC device . Awake, NAD (not skilled nursing)

I've seen both

Much of what I posted is to benefit others who have no idea what is involved such as the fact that since the district pays the bill they can audit the charts (and often do to ensure services are needed). You may not have realized that either. I've done chart QC/QA for a pre-audit and you would be astounded at what some chose to write from details about what a PT session entailed that the nurse was just their to monitor vital signs & tolerance (number of steps, exact exercises, specific equipment used) but almost nothing that justified full time 1:1 nursing in school

[doodlebuttRN]

Much of what I posted is to benefit others who have no idea what is involved such as the fact that since the district pays the bill they can audit the charts (and often do to ensure services are needed). You may not have realized that either. I've done chart QC/QA for a pre-audit and you would be astounded at what some chose to write from details about what a PT session entailed that the nurse was just their to monitor vital signs & tolerance (number of steps, exact exercises, specific equipment used) but almost nothing that justified full time 1:1 nursing in school

JBN, that is really interesting. I do understand that the school reimburses or pays for nursing during the hours the patient is at school (i assume this is exactly why we have to write separate 'school notes' and document the exact time we depart the home for school and the time we return home from school), but I had never heard from a nurse who does the audits/QC/QA for these notes. I mean, we have a medical records person at my agency, but I haven't heard much from them apart from "so and so wrote the wrong time on their last nursing note, it doesn't match their clock out time," etc.

I am curious about what other documentation issues you have come across for private duty as opposed to other area of nursing? It really is very different, and I haven't been told of any issues with my documentation, but that doesn't mean I haven't had any. Just curious if you could offer any thoughts based on your experience in this area?

(I only ask because I see that you give very good, thoughtful feedback in your posts, and it seems like you have a lot to offer those of us who are still finding our way...)

[JustBeachyNurse, LPN]

You really don't want to know. But drawing sketches and writing holiday messages on notes--not a good idea. Don't use unauthorized abbreviations. Don't make up abbreviations. If you don't know use a word you do

C2O2 is not peroxide but ethylene dioxide related to carbon monoxide. H2O2 is hydrogen peroxide

sx is surgery while sxn is suction so performing trach sx multiple times a shift will be questioned as surgery is out of the scope of nursing.

Agencies should have a list of acceptable abbreviations that you can have. If you can't spell it look the word up or choose a word you can spell.

Don't make up weird names for games and use in documentation such as "hide mr. Weenkie" when referring to toileting a school aged child or teen. And that's really what was written "11:30 played hide Mr. Weenkie x7 minutes. No results. Diaper dry. " the parent noticed that first and was horrified at what it could possibly mean regarding her disabled teen son!

If you have an issue with school staff call the office to create an internal incident report. Don't write a two page dissertation including quotes documenting the conversation/disagreement. That's the clients medical record. It's submitted for payment and to justify care.