Documentation

JenTheSchoolRN, BSN, RN · Oct 20, 2017

Hi everyone! I am a nurse at a private school for children with autism and other developmental delays. We just hired a second nurse as our student # and the acuity increased. How do you guys document with multiple nurses? We travel to classrooms to administer medications with our treatment cart, as well as provide care in the office. We are currently charting by paper (hoping to change that soon...) so to have one office log for two people in two separate places seems silly! Any suggestions?

There are two nurses that work at my school, and we work in two different building. Do you have EMR? If you do or can get one, you can create two different log-ins and each chart what you do.

I don't use it currently, but highly recommend SNAP.

WineRN · Oct 20, 2017

I think all you can do since you are using paper is have two separate log sheets, one for each of you, that get filed in one central location.

GetBackToClassRN · Oct 20, 2017

I would consider having individual student logs printed on cardstock that are kept in a central location. You could each have a binder/folder that you place the cards for the students you are passing meds on each day and then they all go back to the central location at the end of each day.

That is how we handled paper charting when I worked in the hospital setting before EMR.

halohg, RN · Oct 20, 2017

Do you have access to a computer and not using an EMR system? If so then I would create a google sheets file and share between the nurses so that each can edit and it can be a live document.

Flare, ASN, BSN · Oct 20, 2017

I would think an EMR program like SNAP or Healthoffice would work best as you can have multiple users. I use Health office, but then, i'm an army of one.

PediNurseNYC · Oct 20, 2017

Thanks everyone! Unfortunately getting an EMR is not feasible for this school year. I am working with the program director to hopefully implement one within the next two school years since that's the best option. I guess i will just have to have two different paper logs for us and put it in one file. NYC regulations require us to have one nursing log for all students instead of each individual student having their own. Continue sending creative ideas! Thank you!!

JenTheSchoolRN, BSN, RN · Oct 23, 2017

Thanks everyone! Unfortunately getting an EMR is not feasible for this school year. I am working with the program director to hopefully implement one within the next two school years since that's the best option. I guess i will just have to have two different paper logs for us and put it in one file. NYC regulations require us to have one nursing log for all students instead of each individual student having their own. Continue sending creative ideas! Thank you!!

Can you reconcile the paper log until a single say, Excel spreadsheet log, at the end of each day for long-term reference? I say this because it may be helpful to track trends, etc because you can sort it and look at overall data. They you can file the paper logs into a file as back-up.

I know this is double documenting, but it one needed to route back through days and days and days of logs, I can imagine it would be very time consuming.

Flare, ASN, BSN · Oct 23, 2017

they just dropped the bomb on me - "We're looking into Care Dox"

I ask very little around here... i like the way i chart. please don't change it because you want to save a few hundred dollars. My efficiency will go in the crapper.

Anyone use care dox? Thoughts???

OldDude · Oct 23, 2017

they just dropped the bomb on me - "We're looking into Care Dox"
I ask very little around here... i like the way i chart. please don't change it because you want to save a few hundred dollars. My efficiency will go in the crapper.
Anyone use care dox? Thoughts???

My thought is that any program used in public schools had the health component written as an afterthought, probably by a social studies major turned infomatic tech. We use Skyward...Just today our entire district lost the ability to run immunization reports - but on the flip side it shows everyone is 100% compliant :). I forgot what whiz bang program we used before this one.

Flare, ASN, BSN · Oct 24, 2017

so i talked to one nurse using it just now - she was using SNAP before and says she likes it more. I just don't know. I still think that the only free cheese is in a trap. Nothing in life is truly free.

MrNurse(x2), ADN · Oct 24, 2017

My wife and I co-nurse our small private. We use SNAP and it is very reasonable, at $315 per year to lease. You could install it on 2 laptops for med pass and dual access. Intuitive for learning, we taught ourselves through their videos.