Pretty much told to lie

[OyWithThePoodles, RN]

So I had two kiddos come in last week who had clearly been in an altercation, (Elementary school). We couldn't get the actual story of who had started it, but they both admitted to putting hands on each other. So I documented in the computer "altercation with another student," etc. and the injury. While filling out the accident reports the principal asked what I was putting and I told her. She then tells me not to put that, to put "unable to get actual story of incident, teacher unsure." (Teacher was a sub who really was unsure, but knows they were fighting)

I then had to call one of the parents and say "So and so ended up on the ground, we aren't really sure how, but he has a place on the back of his head." Knowing full well when the kid gets home he is telling parent his side of what happened. Just curious on how the rest of you would have handled this. My principal is very intimidating. I did refuse to fill out accident reports on the other two kids that were involved because I never laid eyes on them.... but she tried to get me to nonetheless. And then decided since I wasn't filling it out, then it didn't need to be done at all.

[Farawyn]

They said they got in to a fight. SUB said they got in to a fight. The problem was the details of the fight, not that there was an actual fight, yes?

Why did the principal not want to do his/her job?

Ugh, I don't know.

My Principal is good about stuff like this, I'm lucky.

I would want to know why this is an issue.

I maybe would have said "Child states altercation" not observed by Ms. Blahdeblah...

[abc123RN]

On the accident report I only fill out a small section, teacher or sub, whoever was in charge of student/class at time of accident has to to the majority of the accident report here. In my section and in the EMR I put what the student says (no names of others involved), what I see and what I did. The principal has to sign off on the report after I get finished with it but he doesn't have access to the computerized charting on student's health.

[OyWithThePoodles, RN]

Right, everyone agreed there was an actual fight, just not the exact details of who started it and what happened. I kept what I had entered into the computer the same, but as soon as she saw that I was writing "altercation with another student", she said "Oh no, lets not put that...." Like it sounded bad that there was a fight or something. I was in the room when she called the other students parents and she very conveniently left out that there was a fight with that parent also. "We aren't really sure what happened."

And then tried to get me to fill out an accident report on word-of-mouth injuries on two other students. NOPE. (She also tried to get me to fill an accident report out on a kid that ended up with a skull fracture earlier in the year that NEVER crossed through my door.) "Just write it up and have the teacher (who never sent the kid to my room) sign it." Ummm...NOPE.

[Flare, ASN, BSN]

Your charting is your legal document of what you did, heard, and saw. It reflects back onto you. I agree with Farawyn that perhaps in the future you could state that the student states it was an altercation, but if it was pretty clear cut that it was an altercation i'd have no problem charting that too.

As far as how I handle things here - i make injury calls when necessary and needing follow up, just as I would with any other injury. I do not get into any details of the altercation or really mention the altercation - mostly because I don't know the entire story and discipline isn't my wheelhouse. So i'll call and say "Jimmy got hit in the face by another student. I treated him with ice. He does have a swollen lip that you'll want to take a look at when you see him, but beyond that he had no complaints. The principal will have the rest of the details and will be contacting you soon if he/she hasn't already." The parents usually are appreciative of my call and don't ask me too many follow up questions.

[OldDude]

You did what you were supposed to do. As far as you were concerned this isn't any different than someone telling you they had a stomach ache or they fell out of a swing. We always start an assessment with subjective, ambiguous, information. We seldom "witness" any reason for a clinic visit. The course of assessment and treatment isn't any different. Your principal just didn't want to deal with parent involvement over having to report a fight to them. Like he/she can avoid it!! I wonder if your principal would ask a teacher to sigh a report card for a kid they didn't teach?

[tining, BSN, RN]

You must be at my old school! Your documentation is for your license not hers.

[JenTheSchoolRN, BSN, RN]

I document on my end about the injury and use a lot of "student states" or "teacher reports" (as I wasn't there to witness events, all I know is what is told to me) and usually end it with "follow-up on events occurring prior to injury handed off to dean of students."

My deans/principals are great. If I know I need to notify the parent about the injury, I will touch base with them for communication as we often contact together after injury is treated and all students/teachers involved give their statements unless the injury needed dismissal or emergency treatment. I don't handle discipline and tell parents that the dean will contact them if he/she hasn't already.

[SchoolNurseTXstyle]

Ughh no!!! I document what I observe and / or what I am told. END.OF. STORY!

[kidzcare]

I've never had this happen with one of my administrators but I did with another nurse at a skilled facility I work at.

One patient hit another. I had to fill out an incident report and put in what the pt reported to me and another nurse looked over my shoulder and said "That's not what he told me. You can't put that" I told her that I had to document what the pt told me and if she wanted to document something else, then she was welcome to.

[OyWithThePoodles, RN]

Thank you all for your responses!!! I have put a stop to filling out the accident reports (witness section) just what I did for the child. I typically only call if I feel it will warrant a Drs visit or if the parent needs to come pick up the child. In this particular instance she sub was useless, apparently he had been sending injured kids back to class all day.

Anywho, it's just this principal in particular. She is so intimidating and I need to find my voice. This is the first year they have had a nurse so I just need to lay some ground rules I guess.

Y'all are awesome! Thank you.

*Please excuse typos---using the iPhone.

[Windchaser22]

Methinks your administration is trying to avoid a HIB situation.