Daily log documentation, IEPs and health plans

Posted

Hello fellow Nurses,

I am a new grad RN that took a position as a school nurse and I have some questions regarding documentation in the school setting. I did not receive any training and orientation and I want to ensure I get the school in compliance.

1. My school does not have a computer software program for documentation. Currently, we have a running daily log and I was reading post that stated this is a legal catastrophe due to multiple students information on 1 sheet of paper. What do you recommend I do? Should I keep a binder and each student will have a personal log sheet? Would I write a Nursing note every time a student visits the office? If you have sample document from your district can you please post or send.

2. Majority of the students in the school take psychiatric medication. They do not take the medication during school hours. Do they require health plans?

3. What is the nurse involvement with IEPs. No one in my school seems to know and I contacted a nurse from Department of Mental Health and Hygiene and she said let the school worry about that. (That doesn't seem right because if we get audited we will all be in hot water)

The school I work for is private and located in NYC.

I appreciate all help....

nurse_tate

nurse_tate

4 Posts

We used a single sign in sheet for the students to sign when they entered the office before we had them scan their ID's to sign in. We had a column for time in, grade, name, teacher, and time out. We have an "Emergency Health Form" each parent is to fill out. Before we went to computer charting, we would chart on the back of these. We still have the sub-nurses fill the back side out because they can not access the computers.

JenTheSchoolRN, BSN, RN

Specializes in School nursing. 3,027 Posts

When I was a sub nurse, I didn't have access to the computer, so I had a daily log sheet with student's name, grade, complaint, treatment, etc. Each student had an emergency health form that existed in paper and on the computer. Of course, the computer was easier since I was dealing with 1300 students, but luckily the secretary had helped formatted emergency info (contact numbers/allergies/permission to give OTC meds) for the sub nurses.

I do have electronic medical records in my current job, but they don't cover everything. In every student's physical file, I've stapled a lined sheet of paper to inside of the the folder. If the visit is beyond the simple stuff I can input or warrants follow-up, I write a short note on the lined sheet of paper, date it and sign it. Easy access later when I need it. The lesson I've learned in nursing, especially school nursing is document, document, document! :)

skillaz

skillaz

8 Posts

Hi, fellow NYC school nurse. I'm in the public sector. We have ASHR for all the public schools and i think some private schools as long as they have a computer. Technically every student with medical necessity should have a health plan. If youd like to write one up for every student you can, but i do not think its neccessary. Good way for you to set your goals and plan your care but i think health plans are ehh. We are suppose to do it in the public schools, technically but they havent mentioned a thing about it, so im not gonna do any more work then i have to. IEP's are the responsibility of the school and they are suppose to be dealing with it, cuz its more about how to accomodate their medical need's academically. The nurse in my opinion should be involved with the planning and decision making but are not. There usually is someone who has a medical background who is involved with the IEP's so you may not be needed.... but this is only sometimes... Try to get a sample form of a completed IEP and follow from there.

schooldistrictnurse

schooldistrictnurse

Specializes in School Nursing, Public Health, Home Care. 400 Posts

We often attach a health plan to the IEP for students who have significant medical issues such as diabetes, CP, MD, Seizures. Sometimes I will write a section of the IEP called "background information" if there is a significant history, such as kids with complex medical issues coming out of a birth to three program.

As for the meds, you can't physically keep up with constant med changes and know what all your students are on. This is especially not critical since they aren't administered at school. However, when possible, I do ask parents what their kids are on at home, just so I am aware of current practice and can look up common meds. I keep a binder ring with 3x5 cards with current meds just for my own knowledge. ( no student identifiers). This way I know our local docs are prescribing Abilify and I can look it up and be familiar with it. Makes you look like a genius when a parent mentions their kid is on "x" and you can say " be sure they are using sunscreen with that one."

Keep asking, this forum is full of "old salts" who can answer your q's.

RN4STUDENTS

RN4STUDENTS

21 Posts

You would probably benefit from this: Twenty-Fifth Annual School Nurse Orientation August 19–23, 2013 The Lodge Welch-Allyn Conference Center Skaneateles, New York. I've never been but Im a school nurse in NJ and I did register, it looks informative.

NutmeggeRN, BSN

Specializes in kids. Has 39 years experience. 8 Articles; 4,532 Posts

You could also use an Excel spreadsheet. That will allow you to sort by any field you chose. If you need to cull info on a particular kid, diagnosis or injury all you need to do is sort by that particular field. Then you can print only the info you need.

Flare, ASN, BSN

Specializes in school nursing, ortho, trauma. 5 Articles; 4,427 Posts

how do you manage your emergency contact info? do you have a binder of sheets/cards or boxes of cards with parent contact info and student info on it? That's the method we used a few years ago for our students for "sub logs". each sheet had a log attached to it. as the students came in, their card would be pulled and there would be all their info. i'd imagine you could make up a 2 sided copy type sheet to put in a binder with emergency info on one side and a log on the other in that's the method you go with.

RNHD

RNHD

Specializes in Critical Care, Peds. 10 Posts

I think this website will be very helpful to you: New York Statewide School Health Services Center

I would recommend joining your state school nursing association as well. They will have great resources & be very helpful to you! Good Luck!

blueiwahine

blueiwahine

Has 7 years experience. 203 Posts

I just accepted a school nurse position too...thanks everyone for the tips. Our school uses computer skyward, which I haven't learned yet..hear it is a bit complicated