Skip to content
View in the app

A better way to browse. Learn more.
allnurses

A full-screen app on your home screen with push notifications, badges and more.

To install this app on iOS and iPadOS
  1. Tap the Share icon in Safari
  2. Scroll the menu and tap Add to Home Screen.
  3. Tap Add in the top-right corner.
To install this app on Android
  1. Tap the 3-dot menu (⋮) in the top-right corner of the browser.
  2. Tap Add to Home screen or Install app.
  3. Confirm by tapping Install.
Discussion

School day documentation

I attend school with a student with a seizure disorder. There are no tubes, diapers, wheelchairs, no meds to give. I’m not sure what to write in my notes. My role is to monitor for seizures and administer emergency medication if needed. So basically I sit in the back of the classroom and just watch. I write that she is attentive and cooperative with school work.  No seizure activity. I don’t think specifics about her class work is medically necessary to document. Any ideas? 

  • Quote

    • Featured Replies

    • Experts

    Each hour make an entry that there are no signs of discomfort or seizure activity, perhaps a remark about attentiveness or cooperation. Do this for awhile to see if it flies versus the one catch-all sentence at the end of the school day/shift, or ask your clinical supervisor if they want more. I have found, particularly lately, that one could write that the grass is blue and the sky is green and the supervisors/documentation reviewers wouldn’t say boo because they don’t bother to look at documentation and they don’t care. I think hourly or even every two hour entries would at least show you are trying to document correctly.

  • Quote

    Bathroom activity? Lunch? Friendly with peers?

  • Quote

    I just wanted to add, you can also chart that pt is alert and oriented, engaged with peers/teachers, respirations even and unlabored, skin warm and dry, cap refill, etc.

  • Quote

    • Join the conversation

    You can post now and register later. If you have an account, sign in now to post with your account.

    Guest
    Add a Comment
    Go to topic listing

    Currently Reading 0

    • No registered users viewing this page.

    Account

    Navigation

    Search

    Search

    Configure browser push notifications
    Chrome (Android)
    1. Tap the lock icon next to the address bar.
    2. Tap Permissions → Notifications.
    3. Adjust your preference.
    Chrome (Desktop)
    1. Click the padlock icon in the address bar.
    2. Select Site settings.
    3. Find Notifications and adjust your preference.