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I have 3- 1 inch binders divided up alphabetically. Each student has a sheet with 6 visit comment sections on each side of paper. I note the date and time, C/O, brief assessment,interventions, a check box for parent contact and whether student returned to class or went home. It is very time efficient, privacy compliant and easy to locate each record. A card system would be good too, except I would get behind on filing the cards after each visit. My corporation is broke, so not sure if we will ever have electronic charting.
I have a daily log sheet that I write the time in/out name, period in/out (Jr High), ID number, complaint, brief assessment, temp, and check boxes for dispostion (home, BTC, other). I chart each kid individually - we computer chart, but prior to last year it was all hand charting. When it was hand charting each kid had their own card that was a continuous record, if one filled up, we just stapled another to it.
Hope this helps.
I have a daily log sheet that I write the time in/out name, period in/out (Jr High), ID number, complaint, brief assessment, temp, and check boxes for dispostion (home, BTC, other). I chart each kid individually - we computer chart, but prior to last year it was all hand charting. When it was hand charting each kid had their own card that was a continuous record, if one filled up, we just stapled another to it.Hope this helps.
Thanks Chiefswife ! Can you tell me where you purchased the cards from.? (stationary store, etc???)
Thanks so much for your help !
Praiser :heartbeat
Praiser,
our cards are a landscape, 8.5 x 11 sheet, on cardstock. I'll see if I can dummy one up on the computer and email it to you. Other wise, if you are comfortable, you can PM me your school addy and I can mail you one (to "The Nurse", if you prefer). They are a standard form for my district, so we call print shop if we need more.
We use the same kind of system that Chiefswife uses--and we went from individual cards to computer record last year, but maintained the daily log. The log is helpful to track how many kids are seen daily, etc, but the individual record is considered the "legal" record and that is the item that can be requested by an attorney. You couldn't give an attorney the log since it contains multiple student entries. Also, the individual card can be sent with records if the student transfers to another school. We just printed our own form on cardstock--name, DOB and columns for date, time, chief complaint, intervention, disposition and initials.
Flare,
We have seperate "Emergency/Contact" cards witht parent/relative/friend numbers for contact purposes. On the back, there is space for basic med hx (does your child have any DIAGNOSED medical issues such as DM, Asthma, etc?) and allgy info. Also there is a blurb about "by signing, I give permission for you to give my child antipyretic med for temp > 102.0, epi (pen) for allgy rx to food/sting, etc". These are kept seperate, filed in a box for look-up purposes. Some of our campuses keep these in the front office, some in the nurse's office.
Meeka,
be more than happy to. PM me your email addy.
Keepstanding, ASN, RN
1,600 Posts
i am wanting to go to a new system next year for logging students in to the clinic. we do not use an electronic system. i just log them into a spiral bound notebook. with over 1200 kids it's getting frustrating !!
i would like to go to single cards for each student and keep them in a small file box. is there anyone out there who uses this kind of system ?? i would love to know where to purchase these cards.
thanks everyone !!
praiser :redbeathe