Documentation of School Nursing Practice & Health Service Delivery

The school nurse must ensure that there is a plan for communication and documentation of that plan when nursing practice and health services are provided. This communication plan can be written within training, the individual health plan, the emergency action plan or student health records.

Documentation is required when any health service or nursing task is delegated and whenever a health service or nursing task is performed.

Purpose of Documentation

Steps

1. Provides evidence of the nurse’s legal responsibility
2. Demonstrates standards, rules, and laws of nursing practice
3. Reflects professional and ethical conduct
4. Supplies information for cost to benefit reduction or reimbursement
5. Furnishes data for quality assurance
6. Protects students, families, school nurse and schools
7. Reflects assessment and care provided to the student
8. Demonstrates the results of treatment provided
9. Helps to plan and coordinate student care
10. Allows interdisciplinary exchange of information about the student

Basic Principals of Documentation

Steps

1. Entries should be legible, written in blue or black ink if paper charting or in an electronic health record
2. Computerized Records [EHR] should be secure and password protected
3. The date and exact time should be included with each entry
4. Should include any nursing action taken in response to a student’s issue
5. Assessment data should include both positive and negative findings
6. All records should be kept current for individual students, no multiple student visit log
7. Include precise measurements, correct spelling, essential information and standard abbreviations
8. Subjective data should be in the student’s own words
9. Objective data should be factual and relevant to the student’s care or clinical nursing judgement provided by the school nurse or as delegated to the paraprofessional
10. Frequency should be ongoing, consistent over time and based on student’s acuity, nursing protocols or school policy
11. Include the reason for the student’s visit
12. The school nurse’s determination using professional nursing judgement
13. The school nurse’s actions taken in response to a student’s problem or the delegated interventions provided by the paraprofessional
14. The outcomes/disposition of the student
15. The nurses name, paraprofessional’s name, credentials (if applicable)
16. The students name, demographic information with 2 identifiers

Documentation Errors to Avoid and Considerations

1. Avoid failing to document observations or nursing actions. Failure to document produces gaps in the student’s health record suggesting neglect in care.
2. Avoid treating flow sheets for school health services casually. Don’t neglect to record the learner's response to care provided or change in the learner's condition.
3. Avoid altering student health records :
   1. An alteration in the record can make a defensible case, indefensible
4. Consider the importance of documenting in real time.
   1. If a “late entry” is necessary then identify it as such and reference the date and time you are relating back to.
   2. If you need to add additional information to an existing note, then identify the new note as an “addendum” to the date and time
5. Avoid failing to discontinue medication.
   1. School nurses delegate medication, a failure to discontinue a medication can lead to a medication error.
6. Avoid writing Illegibly
7. Avoid documenting personal opinions.
8. Consider recording only:
   1. factual and objective observations
   2. the student’s statements or parent communication to include the inability/reason to not be able to contact a parent
9. Avoid improper corrections.
   1. Never erase or obliterate an error.
   2. Consider correcting an entry, by drawing a singular line thru it, label  it “error”, sign and date
10. Avoid vague or erroneous abbreviations
11. Consider using only standard abbreviations

Three Strategies for Risk Reduction in Documentation

Strategy 1: The school nurse should document full assessment data

1. There are many cases where a nurse fails to document full assessment data leading to accusations of negligence:
2. Document what is not visually assessed, in addition to what is assessed meaning: (e.g. no bruising, swelling, or deformity noted)
3. Nurse documentation should clearly reflect that nurse is monitoring for foreseeable complications
4. Document all communications with the student's parent or healthcare provider: If you placed a call to the parent or if you spoke with the parent in your office, the parking lot, or in a hallway: Document it.
5. If you placed a call to the parent or healthcare provider and there was no answer: Document it.
6. Document your assessment and the student's response to nursing care provided.

Strategy 2: The school nurse or paraprofessional should be precise

1. Be precise in documentation
2. Do not document in advance
3. Always include a date and time
4. Document in the correct student health record
5. Be consistent in your documentation style and method
6. Be factual and avoid:
   1. Labels and unprofessional adjectives, like “appears spaced out” or “acting bizarre”
   2. This hurts your credibility and reflects poorly on your professionalism
7. Avoid assumptions, bias or conclusions, like “the student appears to not have taken her medication this morning at home” or “the parent didn’t take the student to the doctor yesterday after the student was sent home”.

Strategy 3: Documentation and other reports as directed by school districts (e.g. incident and accident reports)

Keep in mind that school incident or accident reports:

1. are "administrative communication”
2. are filed separately from a student’s record
3. are not a substitute for nurses notes or paraprofessional performed interventions
4. nor are nurses notes or paraprofessional documentation a substitute for incident or accident reports
5. can be used as “memory joggers” to document in the student’s health record.
6. used to facilitate decisions about restitution

What is a “memory jogger”?

The United States Department of Education has provided guidance on what records are exempted under FERPA:

“Exempted from the definition of education records are those records which are kept in the sole possession of the maker of the records and are not accessible or revealed to any other person except a temporary substitute for the maker of the records. 

Once the contents or information recorded in sole possession records is disclosed to any party other than a temporary substitute for the maker of the records, those records become education records subject to FERPA. 

Generally sole possession records are of the nature to serve as a “memory jogger” for the creator of the record. 

For example, if a school official has taken notes regarding telephone or face to face conversations, such notes could be sole possession records depending on the nature and content of the notes. 

School nurses many times will provide care away from the environment where documentation can occur immediately. The school nurse may have a "memory jogger" that includes the provision of nursing practice provided to the learner(s) during a crisis or time away from the ability or resources (computer) to document.”

Considerations with Memory Joggers

1. Never consider recreating a "memory jogger" as a form of documentation to show that health services were performed.

2. Dispose of a "memory jogger" once information has been documented in a manner that protects the learner's confidentiality.

3. If a school nurse or paraprofessional is going to store memory joggers, they must be kept in the sole possession of the maker of the record and are not accessed or revealed to any other person except a temporary substitute of the maker of the records. 

4. Always try to document immediately with the provision of care for quality and safety.

5. Do not wait until the end of the day to document.