MrsBRN

I had a teacher do this earlier this month. I had assessed student for being extremely tired, felt warm with hoodie on, and a headache. No temp, was very alert, maybe the dark room made it look like there’s were dark circles under eyes, but no such circles when assessed., sent student back to class and had them hydrate with 8 ounces H2O and out head down for 15 minutes, notified parent of said assessment and parent was fine with student returning. Spoke to teacher and told her, her concerns were expressed to parent. (Wasn’t acting their self, usually very active). She called parent, parent arrived to school, front office called me looking for student “who is with nurse... “?‍ I spoke to teacher, and expressed concern with actions and that when I see and assess a student, what I do/recommend is in me. I document all if it including convo wit parent. But now the documentation doesn’t match the reality. If you question my call, instead call me first. I actually had already told both parent and Teacher that if student continued to complain, I would call parent to pick up. Due to COVID sending kids home with minor symptoms sometimes means an up to 10 day quarantine. So I an hesitant to do this unless my nursing judgement/intuition says to. I also notfied my admin.

Thank you for the replies. I can see how a progress note, once signed can be used as an order, sadly most notes are not signed until well after the patient is gone, or end of the day. The LOS does not show name or a signature, so there is no way of proving who wrote what. The LOS really bothers me. I can get behind a progress note, but in past had a provider change the note to reflect another dx test then one originally, thankfully can see changes when the addend notes, but easier to see changes in orders.

I have a question regarding out patient clinic nursing care and the policies/regulations. Situation: Orders are not placed for certain procedures pertaining to foley insertion/removal/void trials and wound care (simple and complex). The medical providers instead put documentation of what they want done in a progress note or in a comment box in the level of service section (where follow up information goes). I like to follow the rules and the facility has told me that documentation by provider is all that is needed. However when in nursing school (I have been a practicing nursing for about 4 years), I remember having it drilled into us that we needed an order for everything. I realize we focused mainly on acute care and inpatient hospital systems. This is why I am here asking for any information regarding this issue. I have poured over the Texas Board of Nursing, Nurse Practice Act (I practice in Texas), and spent hours going through CMS documentation. I have found nothing that fits the situation. The question: Is an order required to provide the above stated nursing care? If so is that requirement federal/state regulated, or is it facility regulated? What constitutes an order in the setting of an EMR? Does a progress note work or other documentation work? If it is a facility regulated issue I am aware I will need to take it up with them, I am actively seeking clarification from the facility at present. Thank you for any and all guidance.