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Discussion

How would you document this?

I forgot to enter a student's visit to me last Friday into my Health Room Log. I remember the incident and the student's mom called to ask me about it today. Should I now add it to the log with an indication that it was added on 1/23? How would you handle it?

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    I would chart for today.

    For example:

    Spoken with (Student's Mother). Mother states, "my child is sick, can't come to school". Informed mother regarding child's health visit last (Jan. 2013 - Friday) where child complained of (blah, blah, blah). Assessed said patient friday, found (this and that). Given extra fluids, educated about blah blah blah. Called and informed parents regarding child's situation, reinforced education to caregivers.

    I don't know the policy of your school regarding late entries but usually late entries (with headings as LATE ENTRY or ADDENDUM) raises red flags to administration. If you are using a computerized charting, most software would let you do an entry with a different date.

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    that's what i would do. just note it was a late entry. leave it simple.

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    thanks all. That's what I did just wanted to run it by someone else. I also let my prinicpal know about the mother's call, my late entry of data and the result of my call back to the mother just in case the mother calls her.

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