Jump to content

School Nurse Documentation

Posted
ljantzi ljantzi (New) New

New school nurse here!

I cannot locate specifics on documentation for my state or district so I thought I would reach out through here before contacting a colleague in my district. I received zero training or orientation, as the prior school nurse only gave 1 week notice before leaving. But she kept a daily log sheet for each kid that came into the nurse's office and I was told she would entered information into the online school system called Sycamore.

1. What is the purpose of the daily log sheet besides to catch trends? I can't see how it would be a legal document as any personnel writes in this book and no one signs their name to it.

2. Does every bandaid and icepack visit warrant a legal documentation in their official health record?

I want to ensure I am documenting the correct way. Going from acute care for the last 5 years to the school setting is a huge change up, but I know I will love it once I get my bearings! Any advice would be appreciated!

Thanks!

moreoreo

Specializes in School Nursing. Has 3 years experience.

I document every injury I see, even if my only intervention is cleaning and applying a bandaid (or even no intervention at all), in case someone calls and asks if so-and-so came in to see me about whatever body part. I can confidently state whether I saw them, what I saw, and what I did. There is no way I would remember otherwise. It also helps me quickly identify students who are coming in too often.

I also keep a covered daily visit log with just in/out times and where they ended up (class, home) which helps me to identify at a glance whether a student came in on a given day. Have to have this bc we don't have a computer charting system.

Paper charting is slow, tedious, and I don't know how well it would hold up in court but I'd always rather have too much detail than too little!

aprilmoss

Specializes in School Nurse. Has 20 years experience.

I figured a daily log was just a cross check for the per patient record, Confirm whether little Jimmy was in the office on Tuesday as well as Wednesday.

I do periodically generate some statistics (how many kids I see a week, etc...) from the daily logs.

I suppose if the per-student records were on a computer and could be searched I'd not need the dailys.

Farawyn

Has 25 years experience.

I use eSchools. And I document everything.

JenTheSchoolRN, BSN, RN

Specializes in School nursing.

I use eSchools. And I document everything.

I use SchoolBrains (specific to MA, I think) and I also document everything. Even when I give out a bandaid. But I have created drop down shortcuts in my software to make it easier.

This is helpful for trends, legal stuff, and also basic traffic tracking. My boss loves data and since my boss isn't a nurse, that data is something he does understand and helps me a lot when communicating my office needs.

Farawyn

Has 25 years experience.

I use SchoolBrains (specific to MA, I think) and I also document everything. Even when I give out a bandaid. But I have created drop down shortcuts in my software to make it easier.

This is helpful for trends, legal stuff, and also basic traffic tracking. My boss loves data and since my boss isn't a nurse, that data is something he does understand and helps me a lot when communicating my office needs.

The one time you don't document? That will be the time there's a alwsuit aginast the school and they ask for a nurse's note.

moreoreo

Specializes in School Nursing. Has 3 years experience.

The one time you don't document? That will be the time there's a alwsuit aginast the school and they ask for a nurse's note.

That's the mindset I document with too. Even if it's Vaseline for chapped lips, this way I can point at my notes and say "these are the only visits this student ever made to the health office this year."

OyWithThePoodles, RN

Specializes in Med-surg, school nursing.. Has 10 years experience.

I have a book that I jot visits down quickly in, sometimes I get 3 students at once, so there isn't time to chart them in the computer as they come through. I will quickly write down a name and a short description that will help jog my memory of the visit. (J. Doe, s/a, 99.2 or K. Doe, R ankle)

When I get time I document in the computer, but I document on every student that walks into my office. Even if I did nothing for them. Kiddo comes up waning me to pull a tooth, I chart "student asked for nurse to pull tooth, informed student that nurse does not pull teeth, blah, blah"

This helps for the parents whose snowflake tells them they came to see the nurse and I did nothing for them. I can tell them with certainty that A.)I did not see your student today, or B.)I did see your student, they rested without vomiting, I gave them water and a mint and they told me they were fine to return to class.

We use Eschool - I document everything or at least try to, we do not use paper documentation. I will miss a bandaid or ice pack here and there when I am really busy. Majority of the time it is clicking on a drop down menu of items, so it doesn't take that much time. Occasionally I will write a little narrative but most of the time it is very brief.

WineRN

Specializes in NCSN. Has 4 years experience.

We have a computer program (SNAP) where I chart everything except bathroom visits (that would be most of my day if i did that).

On very very busy days, I have a paper log sheet that I use to jot down the students name, main problem, and time in and out. Sometimes I just can't be at because of a rush of skinned knees and possible concussions and reported vomiting little ones all marching in at the same time

Amethya

Specializes in Cardiology, School Nursing, General. Has 5 years experience.

I have completely different instructions, as such because I'm just a CMA, not an RN or LVN. I call parents and document EVERYTHING, doesn't matter what is for. If it's a small bandaid, I don't say anything, but it's something like a bleeding cut or such, I do call parents. I would say maybe this could be safest route for you.

kidzcare

Has 5 years experience.

I document every injury I see, even if my only intervention is cleaning and applying a bandaid (or even no intervention at all), in case someone calls and asks if so-and-so came in to see me about whatever body part. I can confidently state whether I saw them, what I saw, and what I did. There is no way I would remember otherwise. It also helps me quickly identify students who are coming in too often.

Assessment is an intervention ;)

moreoreo

Specializes in School Nursing. Has 3 years experience.

Assessment is an intervention ;)

A much needed reminder in my elementary world where only ice packs count as "something" :)

I document everything, and use Synergy, with paper log slips (that are designed to match) in my schools when it gets too busy. My health aides enter those at the end of the day, or throughout if time allows.

Everyone has to login, so there is an electronic signature attached to each entry.

I document phone calls. It is just like acute care- you won't remember reliably, and without documentation, you have nothing to indicate what you did was done.

Good luck.

nursekoll, BSN, RN

Has 15 years experience.

My school switched to Infinite campus this year and I'm still figuring it out. I keep a file on my computer for personal records highlighting each day's occurrences, but record all nurse visits either in the infinite campus "health office visits" or if it's just a cough drop, I put it in the medication logs. I also keep a paper log form, but no one else ever fills it out, so I don't have any idea what happens when I'm in other buildings! If someone has ideas for how to get the secretary to keep a record, please let me know. Mine are "too busy" to write anything down (except medications- I told them they HAD to write those down). I'm typically only in each building one day a week.

Thanks for everyone's input! Documentation appears to be just as critical in the school nurse world as it is in the hospital world.

The office staff at the elementary school is wonderful about keeping a log of students that come into the office, the time, the complaint, and the intervention when I am not in my office. This is information I really want to show up in their health records so I am wondering if I should enter the information at it is written and notate that it was done by "office staff." The bad thing is they do not sign who the person logging the information is. Thoughts...

NutmeggeRN, BSN

Specializes in kids. Has 25 years experience.

Check in with, and join, your state school nurses association, as well as NASN. They have a plethora of information.

OyWithThePoodles, RN

Specializes in Med-surg, school nursing.. Has 10 years experience.

Thanks for everyone's input! Documentation appears to be just as critical in the school nurse world as it is in the hospital world.

The office staff at the elementary school is wonderful about keeping a log of students that come into the office, the time, the complaint, and the intervention when I am not in my office. This is information I really want to show up in their health records so I am wondering if I should enter the information at it is written and notate that it was done by "office staff." The bad thing is they do not sign who the person logging the information is. Thoughts...

I had asked the boss lady about this once and she said not to document anything that I didn't do. I am rarely out, but if I have to run to another school the office staff will see kids. That said, if a student is still in my office when I get back, I will chart something like "Student in office when nurse arrived, Jane Doe, office staff took temp, 100.9, they called parent to pick up, student currently resting in office." Or "Student in office when nurse arrived, resting on health mat. Office staff states he said vomited in the restroom, monitored for 10 minutes with no vomiting and returned to class."

If you don't see the student at all, I likely wouldn't chart it. If you want to keep a log of some sort, type something up like you have that has a signature line and speak to the office staff and tell them they have to sign it.