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New sn 2 weeks in...

Posted

Hi everyone!

So I am almost 2 weeks in as an elementary school rn. I am a little baffled by the amount of documentation and the number of places to document in. We use healthmaster, so everything gets documented there, but we also have paper charts, then separate paper charts in a separate drawer for any kids on sched or prn meds, then on top of that, the papers in those paper charts are a lot of re-written information on different papers. Care plans for this and that and emergency info on every sheet- when really its all in the computer and the emergency care plans and that's where we look, but we have to re-write it everywhere. Is this the norm? It seems silly to me to re-write the same info at least 3 times. I thought documentation in the hospital was bad!

Besides for that, I have to say I love it so far! I love working with kids and I love the schedule!

OldDude

Specializes in Pediatrics Retired.

Sounds like some practices that are hanging on from someone not accepting the age of electronic medical records. With few exceptions like vision/hearing referrals or med permission forms (or computer problems or power failure), I have evolved to where I don't write anything on paper; everything is recorded electronically. So see, you can teach an old dog new tricks!! Maybe you can try it at your district.

Flare, ASN, BSN

Specializes in school nursing, ortho, trauma.

i would utilize healthmaster's report printing capabilities if they are that ansty in the pansty about having that many hard copy reports. I use hm too - i personally only chart once. The only thing i've stopped doing it charting the vaccines twice -we use a written card for vaccines so it seemed silly to put them into the computer. That has become a true "i have absolutely nothing better to do" type task.

I am transitioning to using electronic charting of kids coming in to see me. I do keep a list on my desk so I don't forget to add anyone into the system but I find I don't want to get rid of the list when I'm done inputting. Baby steps but I'm determined to get this all on the computer this year.

JenTheSchoolRN, BSN, RN

Specializes in School nursing.

Those before me didn't use electronic documenting to its full potential, so I have been transitioning to using it it pretty much exclusively. I hate documenting the same thing four times! ;)

I do have files for student's paperwork, but everything else goes into SNAP. I use it for medication administration, visits, glucose checks and enter in immunization, physicals, vision/hearing/postural screenings. Makes my life so much easier when I run reports to see whose paperwork I need to track down :).

We do still have physical health form cards with parent info, OTC permission, updated need-to-know health info, however. This is mainly for subs, though, as they can't access SNAP (I wish they could!).

Jen

Wave Watcher

Specializes in Community Health/School Nursing. Has 7 years experience.

We use SNAP also and I only chart in SNAP. Ain't no one got time to double chart around here! :-) I also have a sub folder that I have paper medication logs, clinic logs and documentation logs for the subs (they also can not use SNAP). We have been having a little issue with SNAP and immunizations. There are times when a child is non-compliant but it doesn't catch it. Grrrr...so, now I feel like I have recheck all my immunizations. Thank goodness we only have 60 kindergartners to recheck.