Health room log examples

Specialties School

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I was wondering if any of you minded sharing what your daily logs look like. The one I'm currently using isn't very good. It has the date, time, reason for visit (a very small area to fill in), and then a list of problems (illness, first aid,medication admin,health education,rest, etc.) that can be check marked. I like the idea behind it but I don't feel it's detailed enough. Do you have a short list like this and then fill out a more detailed on that goes in the student's chart? What do you put in the student's personal chart? Every stomach ache they come in with? I've just been putting in letters to parents I've written and issues such a lice or daily med logs. Thanks so much for your help!

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A one page daily log is illegal unless it is electronic and can be separated into individual records.

So I am assuming you are talking about an individual student log / clinic visit form that eventually goes into an individual student file.

Links:

http://www.aea10.k12.ia.us/divlearn/hsrtforms/healthroomlog.pdf

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Yes, thank you. That's exactly what I've been looking for.

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Specializes in LTC.

My daily log includes: first name, last name, grade, complaint, treatment, parent contact ? teacher contact? home ? return to class?

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You can have a log that includes first name, last name, grade, parent contact ? teacher contact? home ? return to class - that is directory information perr both FERPA and HIPAA.

Complaint and treatment are personally identifiable health information, and cannot be documented in a multi student permanent log (unless it is electronic, where it can be sorted out with the push of a button). It is a FERPA privacy violation and is not best nursing practice - it is the equivalent of documenting all of your nurses note's in a hospital by date rather than by patient. It makes it impossible to ppull together all of the information on one child. See the attachment example in the above note - the record has to be one student's information only.

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Specializes in LTC.
You can have a log that includes first name, last name, grade, parent contact ? teacher contact? home ? return to class - that is directory information perr both FERPA and HIPAA.

Complaint and treatment are personally identifiable health information, and cannot be documented in a multi student permanent log (unless it is electronic, where it can be sorted out with the push of a button). It is a FERPA privacy violation and is not best nursing practice - it is the equivalent of documenting all of your nurses note's in a hospital by date rather than by patient. It makes it impossible to ppull together all of the information on one child. See the attachment example in the above note - the record has to be one student's information only.

THats my daily log ! I don't make the rules I just get paid to follow them. ANd yes it is electronic, and all this info is sorted and subtotaled every month to complete the monthly report.

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If it is electronic, then there is no problem.

" don't make the rules I just get paid to follow them."

All "rules" become outdated and out of sync with best practices. My favorite aspect of school nursing is being your own boss and having more control over nursing practice. If there is a policy that is not best practice, it is a lot easier to change in a school setting than in the acute setting. There are a lot of times that you do not even need to ask anyone's permission to make a change. If there are permissions needed, there are usually fewer layers and less investment in " the way we have always done it".

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Specializes in LTC.
If it is electronic, then there is no problem.

" don't make the rules I just get paid to follow them."

All "rules" become outdated and out of sync with best practices. My favorite aspect of school nursing is being your own boss and having more control over nursing practice. If there is a policy that is not best practice, it is a lot easier to change in a school setting than in the acute setting. There are a lot of times that you do not even need to ask anyone's permission to make a change. If there are permissions needed, there are usually fewer layers and less investment in " the way we have always done it".

Thanks. I actually did research FERPA and learned alot. I'm just so shocked that I have been working for 3 years in this position and not one person who has authority over told me about FERPA until yesterday, when I told my boss about HIPPA and she told me that we don't use HIPPA in the school system. I really had do no idea. You're right if something is not being put into place than its up to me to make changes too. Thanks so much bergren, I think I'm going to learn alot from you. Take care ! :yeah::yeah:

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What electronic charting system would you recommend? My budget is tight and I doubt my school system would pay for this for me without using my budget. So one on the cheaper side would be best.

Another question... I understand that we should only chart daily with the students name, grade, parent contact and rtc. So should I chart the actual complaint and treatment on an individual paper and put that into their chart? Does that include every c/o stomachache, headache and cut that comes in the office?

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Specializes in Cath Lab, OR, CPHN/SN, ER.
If it is electronic, then there is no problem.

" don't make the rules I just get paid to follow them."

All "rules" become outdated and out of sync with best practices. My favorite aspect of school nursing is being your own boss and having more control over nursing practice. If there is a policy that is not best practice, it is a lot easier to change in a school setting than in the acute setting. There are a lot of times that you do not even need to ask anyone's permission to make a change. If there are permissions needed, there are usually fewer layers and less investment in " the way we have always done it".

We tried electronic earlier this year, but we dropped it. It was attached to the program the schools use to enter grades/change courses/etc...

It went well, except I had almost no internet access in my office (nothing new) so I could lose connection in the middle of charting. It was also difficult to retrieve, it'd take us at least 20 minutes to get something printed if we needed to, and there was no way to document if someone went in and changed something. From a legal standpoint, we'd be in deep water if something happened, so we're back to pen and paper!

I'd be happy to send you a copy of what I use to document. Almost every student I see gets a note (unless they stick their head in and ask for a pad).

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Thanks for the info. I'd love to see your paperwork. I'm desperately trying to make my clinic as sufficient and legal as possible!! ha ha my email is [email protected] Thanks again!

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"should I chart the actual complaint and treatment on an individual paper and put that into their chart? Does that include every c/o stomachache, headache and cut that comes in the office? "

The standard of school nursing practice is that you document the nursing process for each child with a health issue, your assessment and intervention. For the common stuff, you can design a checklist to speed up documentation. You should document each phone call with a doc, community provider and parent, and some conversations with teachers if appropriate and about their role in the child's care.

I honestly did not document the fluff - safety pins, tampons, etc, but I do know school nurses who do. They want to make sure every contact with a child is documented and that the nurse is credited with taking care of the student's needs. I see their point.

Electronic health systems - others can weigh in -I know these meet legal requirements for school health office records.

Google:

SNAP - School Nurse Assistant Program

Healthmaster

Welligent - web based - very secure

School Nurse Manager - Marshalltown Iowa

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