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]

My familiarity with these situations is that the child has a nurse with him/her at school because the child needs that level of nursing care no matter where he/she is and the payment structure isn't altered since its school vs a trip to the park, for example and the school district has nothing to do with it.

The school provides the one on one aide, I thought the agency is paid by Medicaid via a lump sum per case because it is deemed the most cost-effective way, perhaps this is unique to my state.

I would think if a child's skilled nursing care is integral to the school district the agency would be part of the IEP, (multidisciplinary meetings that take place annually) and should voice concerns in that environment.

[JustBeachyNurse, LPN]

My familiarity with these situations is that the child has a nurse with him/her at school because the child needs that level of nursing care no matter where he/she is and the payment structure isn't altered since its school vs a trip to the park, for example and the school district has nothing to do with it.

The school provides the one on one aide. I thought the agency is paid by Medicaid via a lump sum per case because it is deemed the most cost-effective way, perhaps this is unique to my state.

I would think if a child's skilled nursing care is integral to the school district the agency would be part of the multidisciplinary meetings that take place and should voice concerns in that environment.

Generally Medicaid does not fully pay for nursing at school. Through the special education Medicaid initiative the district may be reimbursed around $20 per day for skilled nursing. But per IDEA the public school district is legally obligated to pay for 1:1 private duty nursing if necessary for a student aged 3-21 to access a free and appropriate public education. At ~$30-80/hr for a 1:1 PDN (depending on the area and level of skill) of course the district would rather reduce expenses if possible by using a paraprofessional and if in district, a staff nurse.

Medicaid picks up the balance of the daily hours outside school usually maximum 16/day so if school is 6.5hrs a day including transportation Medicaid pays for 9.5 hours those days and 16hrs for weekends and days closed.

The agency or nurse representative should be invited to IEP and interdisciplinary meetings to offer input and be apprised of expectations.

[JustBeachyNurse, LPN]

In my state as per the latest public release Medicaid reimburses public school districts $19.42 for RN and $18.37 for LPN per DAY for skilled private duty nursing. Less than most agencies pay nurses per hour.

[nursel56]

Thanks, JBN. I sort of preferred my naive delusion that funding was not a labrynthine hellscape. You're a great resource and I appreciate it.

[qnmimi]

Here in lies the rub. She IS paid to assess his communication skills specifically by the family who employs her through her employer. If she is not specifically assessing his educational experience, she is not overstepping her legal boundaries. Cognition, and verbalization are an accepted nursing assessment in all arenas of health care, It does sound like the school is attempting to control her legal practice of nursing, and her employer, and the child's parents should be the ones to stop this behavior.

[QuietRiot]

Why is the school assuming that you are writing about things other than nursing? Something just doesn't seem right. Were they recently sued,lol ?

[Hoosier_RN, MSN]

My familiarity with these situations is that the child has a nurse with him/her at school because the child needs that level of nursing care no matter where he/she is and the payment structure isn't altered since its school vs a trip to the park, for example and the school district has nothing to do with it.

The school provides the one on one aide, I thought the agency is paid by Medicaid via a lump sum per case because it is deemed the most cost-effective way, perhaps this is unique to my state.

I would think if a child's skilled nursing care is integral to the school district the agency would be part of the IEP, (multidisciplinary meetings that take place annually) and should voice concerns in that environment.

In IN, it's paid by MCD as well, not the school. I worked for an agency that was strictly private pay or MCD, and sent many nurses to school with kiddos. But never had an issue like this, either