Documentation forms

[LynneM64]

I am new to school nursing, and am still confused about documenting a student's visit. (I have K-5). We have computer programs Dyn-o-log and Dyn-o-mite, but I don't feel like I have the time to type in notes. In VA, the nurse had a card for each child (5X7 or so), and on it they wrote one or 2 lines in the soap format, and it was done. That way it was easy to see how often and why the child was seen. What do you do? I am still more comfortable with pen and paper, but if the computer really is easier...let me know what you think! It is so great having a support group! Lynne

[Keepstanding, ASN, RN]

Hi Lynne,

I have a large 3 - D-ring binder that I use to log each student. Each student has a page in the book. At this time of the year, some of the kids now have 2 pages .. I doccument the date, time of visit, what the problem is and what intervention I used. Also the time they left the clinic or went home. And also is I communicated with the parent. This seems to work for me better that the computer. (who has time to log each child in the computer, when you get 4 or 5 sent to you at a time) Geezzzz

It is a quick reference and it is good to be able to look at a glance why the student is being seen and when they generally come in. It is good to see if there is a pattern developing. ie( always get's a headache during math class)

When a student reaches about 25 visits, I send a "frequent flyer" letter home to the parent, to clue them in to the frequency of their child's clinic visits. This usually stops the frequent " malingerer " syndrome !

I make sure I keep these doccuments for about 7 years and then I will shred them. We sure do have a lot of paper to contend with, but I prefer a hard copy best. Good Luck to you