What do you document...

ohiobobcat · Sep 20, 2016

I don't document feminine hygiene product visits ("Can I have a tampon?"), unless I medicate them as well. Everything else gets documented.

JenTheSchoolRN, BSN, RN · Sep 20, 2016

I don't document feminine hygiene product visits ("Can I have a tampon?"), unless I medicate them as well. Everything else gets documented.

I actually created a drop down for "needs pad/tampon" and also "Requests/need to use office restroom" because I have to document everything. I use School Brains (specific to MA, I believe) and it does allow for me to build in custom things to make my documentation time easier.

kidzcare · Sep 20, 2016

I actually created a drop down for "needs pad/tampon" and also "Requests/need to use office restroom" because I have to document everything. I use School Brains (specific to MA, I believe) and it does allow for me to build in custom things to make my documentation time easier.

I can't create a template in e-school, but I document it as hygiene and then in my narrative type "request sanitary napkin"

Windchaser22 · Sep 20, 2016

Everything. Students need a pass to see me unless it's an emergency or involves vomit or epistaxis (teachers think that is an emergency). The pass helps with charting...a lot.

coughdrop.2.go, BSN, RN · Sep 21, 2016

I have to do SOAP charting for every student I see. If a student just gets a bandaid or cough drop from the front desk there's a tally log for that. When I see 25+ students and have to do hand written SOAP on each one, the charts stack up.

jbiddle · Sep 24, 2016

What about when you're doing screenings? These are the hardest times for me to keep up with who comes in for what except the ones that have a pass. During recess is the only time they don't have to have a pass (My school is approx 770 1st-3rd graders). I may or may not have a helper when I'm doing screenings, and it takes me several days to get them all done.

Bevp · Sep 24, 2016

I actually have an assistant to enter all the data from vision & hearing test (530+ kids)I did the entering last year and it seemed like I would never finish.

I had 5 volunteers to conduct the test for me, too. I planned for this year:-)

TuesdaysChild · Sep 24, 2016

I am only working towards nursing school currently, so give my opinion any weight you like. However, I've been a court reporter for 11 years and have a unique perspective from the legal side that I often find many nurses never considered because, obviously, nursing school isn't law school. If you find yourself in some way involved in a lawsuit in your capacity as a nurse and your notes are lacking in detail, etc., a lot of nurses think they can just be sworn in and explain what was meant or, oh, I probably just forgot to put it there or was busy, etc. And while that is definitely true that you can do that, a judge or jury is not bound to believe what you say. They can disregard the entirety of your testimony and are, in fact, specifically instructed that they don't have to give your testimony any weight.

I've seen several instances of healthcare professionals attempting to augment or supplement their notes after the fact while on the witness stand because they didn't include enough detail on the date of occurrence, but later explanations are given very little credibility in the legal world. It's best to include all the detail you can at the time. And again, that's my advice as a legal professional, not a nurse. But it's important to consider things from a legal standpoint as well because it's such a litigious society. I'm to the point where I see **everything** as a potential lawsuit!!

kidzcare · Sep 26, 2016

I am only working towards nursing school currently, so give my opinion any weight you like. However, I've been a court reporter for 11 years and have a unique perspective from the legal side that I often find many nurses never considered because, obviously, nursing school isn't law school. If you find yourself in some way involved in a lawsuit in your capacity as a nurse and your notes are lacking in detail, etc., a lot of nurses think they can just be sworn in and explain what was meant or, oh, I probably just forgot to put it there or was busy, etc. And while that is definitely true that you can do that, a judge or jury is not bound to believe what you say. They can disregard the entirety of your testimony and are, in fact, specifically instructed that they don't have to give your testimony any weight.
I've seen several instances of healthcare professionals attempting to augment or supplement their notes after the fact while on the witness stand because they didn't include enough detail on the date of occurrence, but later explanations are given very little credibility in the legal world. It's best to include all the detail you can at the time. And again, that's my advice as a legal professional, not a nurse. But it's important to consider things from a legal standpoint as well because it's such a litigious society. I'm to the point where I see **everything** as a potential lawsuit!!

This is good advice though I think you may have thought this was the nursing school forum and not the school nurse forum.

I do remember one of my instructors in school being very adamant about charting and lawsuits. I remember her repeating "If you didn't chart it, it didn't happen"

KSM-RN, BSN, MSN, RN · Sep 26, 2016

I chart everything, even bathroom use. We had budget cuts last year and we were cutting staff based on acuity. Luckily we have a decent software charting system. But its less likely they will cut a nurse position if you see 60-75 visits a day.

Nurse_JackieVA, BSN, RN · Sep 27, 2016

I actually have an assistant to enter all the data from vision & hearing test (530+ kids)I did the entering last year and it seemed like I would never finish.
I had 5 volunteers to conduct the test for me, too. I planned for this year:-)

This seems like a good idea. I haven't started yet - tomorrow is the big day - but if this is on my list of things to do this school year I'm going to see if I can get some volunteers or maybe some student nurses.