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Documentation...Can it be done?

School   (459 Views | 4 Replies)
by Nurs13 Nurs13 (New) New Nurse

40 Profile Views; 1 Post

As a school nurse, are you able to document for another nurse doing an assessment on a student? Also, if a parent comes in, are you able to document any questions the parent asks the student regarding their health status (sick or injury)?

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halohg has 25 years experience as a RN.

216 Posts; 2,488 Profile Views

I would say yes, just document the name of the nurse doing the assessment and use quotes. And yes to your 2nd question. I code this under communications or “parental role” in my system and again use quotes within my documentation. I keep it simple and direct.

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Flare is a ASN, BSN and specializes in school nursing, ortho, trauma.

2 Followers; 5 Articles; 4,164 Posts; 35,522 Profile Views

i try to document all encounters - even the parent questions and phone calls, but when i'm hustling, some of the minor calls may fall off my map (Jimmy has a stuffy nose, etc).  If it's an assessment done by someone else (usually EMS, since i work alone) i usually just say that they made an assessment and may note anything that's notable that they do in my presence.  (i.e. EMS arrived, assessed student, medics took BG - result per medic was 56)

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ruby_jane has 10 years experience as a BSN, RN and specializes in ICU/community health/school nursing.

4 Followers; 2,735 Posts; 11,300 Profile Views

The first question - why isn't nurse 1 documenting? Once I got past that, I would note "Per Nurse 1....."

 

Second question - absolutely, all the time. What ERH are you using? Skyward has a student notes page off of the office visits screen but I have, in a pinch, entered this kind of communication as an office visit because it took so long.

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by ARN Member Nurse

ARN specializes in medsurg/school nurse.

68 Posts; 165 Profile Views

when i am out and i can't get a sub my admin team have to cover for me. I will document meds they passed while I am out and make a note of who passed the med.

if i get a sub they are able to login using a sub login and document themselves. 

I try to document parent phone calls. sometimes I'll add a note to the students visit about it. or if it was a stand alone call without a visit from student I will chart it as its own occurrence. especially if i want to make sure and have a record of how many times I have requested a parent bring in more meds/supplies/or return paperwork needed. 

 

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