What do you document...

GmaPearl BSN RN · Sep 20, 2016

Yupâ€¦ The complaint, the observation, the action. Cuz you just never knowâ€¦

shark_nurse14, BSN, RN · Sep 20, 2016

I have a daily log I use everyday that has the following: date, time in, name, grade, CC, assessment, tx, time out, and whether they were dismissed or sent back to class. I also always write whether or not I tried to call home, just to cover my bum if a parent says they were never notified. I find keeping a daily log helps me see trends (like how everyone's sick on Mondays, but miraculously no one's sick on pajama day).

At the end of the day I write the encounter in a student specific log that I keep in everyone's files (it has the same categories, except the top of the page has their name and grade). Double documenting has saved me in the past so I don't think I'd ever not do it. Fortunately, I'm in a small enough school that I only see 20-30 kids/day so double documenting isn't too time consuming.

OyWithThePoodles, RN · Sep 20, 2016

I chart everything that walks through my door to see me. This is how our District Coordinator justifies the nurses we have and fights for more. She can print out a log that shows how many students the nurses saw each year.

It is time consuming, but if it means possibly getting a nurse in every school...I'm down.

MrNurse(x2), ADN · Sep 20, 2016

Everything!!!

BeckyESRN · Sep 20, 2016

I document them all. Unfortunately, our charting system doesn't have an "invisible boo boo" or "faking sick because I hate math" section

Flare, ASN, BSN · Sep 20, 2016

i try to document everything that walks through my door. Occasionally I get what i call a "drive by" which is a student that runs in for a bandaid or an ice pack and applies it and sticks it back so fast and it out the door before I can even ask their name because I was busy doing something else. It's rare as I can usually id the students by sight but it does happen from time to time

NutmeggeRN, BSN · Sep 20, 2016

I document them all. Unfortunately, our charting system doesn't have an "invisible boo boo" or "faking sick because I hate math" section

I use MMS and was able to build a code for "other" and will make a note...3rd time 3rd block, 4th Monday, etc

DEgalRN · Sep 20, 2016

i try to document everything that walks through my door. Occasionally I get what i call a "drive by" which is a student that runs in for a bandaid or an ice pack and applies it and sticks it back so fast and it out the door before I can even ask their name because I was busy doing something else. It's rare as I can usually id the students by sight but it does happen from time to time

Me too! I do get some in and out for band aid or feminine products too, and I try to document them, but I don't worry too much if I don't if I'm working on some one else.

Otherwise, I try and document everything.

kidzcare · Sep 20, 2016

Yupâ€¦ The complaint, the observation, the action. Cuz you just never knowâ€¦

I chart everything that walks through my door to see me. This is how our District Coordinator justifies the nurses we have and fights for more. She can print out a log that shows how many students the nurses saw each year.
It is time consuming, but if it means possibly getting a nurse in every school...I'm down.

These are pretty much what I was going to say.

Every paper cut, every bandage, every cracker is accounted for. I even document a student bringing in a medical note. It justifies my position and it's all about CYA

bell1962 · Sep 20, 2016

Me too! Sorry forgot to quote. I document everything too, but occasionally I get a "fly by" too

AdobeRN · Sep 20, 2016

I also document everything - occasionally I will miss a bandaid or ice pack, but pretty much anything walking thru my doors gets documented. We use E-school so there is a drop down menu to quickly pick the reason for office visit, intervention & outcome and an area to write additional details if needed.