School Nurse Documentation

moreoreo · Sep 11, 2017

Assessment is an intervention

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

Snappykelly · Sep 11, 2017

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 · Sep 12, 2017

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.

ljantzi · Sep 12, 2017

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 · Sep 13, 2017

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

OyWithThePoodles, RN · Sep 13, 2017

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.

WineRN · Sep 13, 2017

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 enter in everything that comes into the health office. When I go to lunch I leave a log sheet for the person who covers me and when I return I just chart "While at lunch, XD saw little bobby who reported XX and she gave him XX"

We track all injuries here so I like to make sure that I have everything accounted for.

ruby_jane, BSN, RN · Sep 13, 2017

New school nurse here!
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.

I use it as a memory aid, and then shred at the end of the year. Between my aide and me, 99.9999% of everything on there gets logged into Skyward. Plus, it's also a great second line when I have a parent call/come in wanting to know why sweet baby was counted absent when s/he was at the nurse's office. There's not enough info on the sheet to identify a person AND on the occasion where I am monitoring vitals/neuro - it's a really quick and easy place for me to jot that all down and chart it later.

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

Yes. As previously stated, cover your assets. Because you want to chart not only what you did but what you said. Had a parent text my principal a picture of a horribly swollen ankle once. Kid was told to RTC for more ice and reassessment, and to elevate the extremity...and did none of those things. Good luck!

SchoolNursey · Sep 15, 2017

We use a computer charting system, but I document EVERYTHING! Every parent call, student encounter, etc. It has saved my behind more than once.