Documentation...Can it be done?

[Nurs13]

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)?

[halohg, RN]

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.

[Flare, ASN, BSN]

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)

[ruby_jane, BSN, RN]

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.

[ARN]

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.