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DOCUMENTATIONDOCUMENTATIONJUST DO IT!JUST DO IT!
Rachel Gallagher, R.N., A.P.N.P.Rachel Gallagher, R.N., A.P.N.P.Wisconsin Department of Public InstructionWisconsin Department of Public Instruction125 South Webster Street 125 South Webster Street Madison, WI 53707Madison, WI 53707(608) 266-8857(608) [email protected]@dpi.wi.gov
OverviewOverview
What is documentation?What is documentation? PurposePurpose General PrinciplesGeneral Principles Laws and School PolicyLaws and School Policy Types of documentationTypes of documentation Type of recordsType of records
DocumentationDocumentation
Written evidence of the interaction between Written evidence of the interaction between and among students, families, school staff, and among students, families, school staff, health care professionals, regarding care, health care professionals, regarding care, training, consultation, student education, and training, consultation, student education, and the results or response to the intervention.the results or response to the intervention.
Written record of nursing process to deliver Written record of nursing process to deliver care.care.
Purpose of DocumentationPurpose of Documentation
CommunicationCommunication Legal EvidenceLegal Evidence ResearchResearch EducationEducation Quality AssuranceQuality Assurance StatisticsStatistics ReimbursementReimbursement
General Principles of DocumentationGeneral Principles of Documentation
TimingTiming
PermanencePermanence
AccuracyAccuracy
SequenceSequence
General Principles, cont.General Principles, cont.
AppropriatenessAppropriateness
CompletenessCompleteness
Standard Terminology – NANDA and Standard Terminology – NANDA and abbreviationsabbreviations
Legal AwarenessLegal Awareness
What should be avoided?What should be avoided?
Errors in chartingErrors in charting
Reference to district issuesReference to district issues
Terms Terms
Late entriesLate entries
Laws and School PolicyLaws and School Policy
Family Educational Rights and Privacy Act of Family Educational Rights and Privacy Act of 1974 – FERPA1974 – FERPA
Health Insurance Portability and Health Insurance Portability and Accountability Act of 1996 – HIPPAAccountability Act of 1996 – HIPPA
Code of EthicsCode of Ethics
The nurse safeguards the clients’ right to The nurse safeguards the clients’ right to privacy by judiciously protecting information privacy by judiciously protecting information of a confidential manner.of a confidential manner.
Types of DocumentationTypes of Documentation
Direct CareDirect Care
DelegationDelegation
Health PlansHealth Plans
504 and IEPs504 and IEPs
Direct CareDirect Care
SOAP Format of ChartingSOAP Format of Charting
HC- Health ConcernHC- Health Concern
S- SubjectiveS- Subjective
O-ObjectiveO-Objective
A-AssessmentA-Assessment
P-Record PlanP-Record Plan
Delegation DocumentationDelegation Documentation
Date and time of trainingDate and time of training
Willingness to assume responsibilityWillingness to assume responsibility
Competency checklist of skillsCompetency checklist of skills
Contact information for questions or changes Contact information for questions or changes in health status.in health status.
Individual and Emergency Individual and Emergency Health Care PlansHealth Care Plans
IHP – Addresses actual or potential responses IHP – Addresses actual or potential responses to a student to a health care condition. to a student to a health care condition. Carried out in part by the nurse.Carried out in part by the nurse.
ECP – Deals with a specific potential medical ECP – Deals with a specific potential medical emergency. Can be carried out exclusively by emergency. Can be carried out exclusively by other staff through training and delegation.other staff through training and delegation.Step by step in nature. Step by step in nature.
Use Nursing ProcessUse Nursing Process
IHP templatesIHP templates
504 Definition504 Definition
1. Physical and Mental Impairment1. Physical and Mental Impairment
2. Record of Such Impairment2. Record of Such Impairment
3. Limiting a Major Life Activity3. Limiting a Major Life Activity
504 Plan Documentation504 Plan Documentation
Many variations in plan. Typically include:Many variations in plan. Typically include:• Nature of concernNature of concern• Basis of determination of disabilityBasis of determination of disability• How the disability affects a major life activityHow the disability affects a major life activity• Supplemental aids, services and accommodations (reasonable Supplemental aids, services and accommodations (reasonable
and comparable)and comparable)• Review and reassess dataReview and reassess data• Participants names/titlesParticipants names/titles• Case ManagerCase ManagerIHP can become a variation of a 504 Plan or be utilized to IHP can become a variation of a 504 Plan or be utilized to
write a 504 plan.write a 504 plan.
Individualized Education PlanIndividualized Education PlanNursing DocumentationNursing Documentation
PLAEFP – Present Levels of Academic and PLAEFP – Present Levels of Academic and Functional PerformanceFunctional Performance
Additional Testing – Observations, rating Additional Testing – Observations, rating scales, time on task studies, screenings.scales, time on task studies, screenings.
Related Services ******Related Services ****** GoalsGoals Supplemental Aids and ServicesSupplemental Aids and Services Program ModificationsProgram Modifications
IEP: PLAEFPIEP: PLAEFP
PLAEFP – Present Levels of Academic and PLAEFP – Present Levels of Academic and Functional PerformanceFunctional Performance
Brief statement of health diagnosis, medications, Brief statement of health diagnosis, medications, health needs at school and concerns that impact the health needs at school and concerns that impact the ability to learn.ability to learn.
Example: 3Example: 3rdrd grade student with three-year history grade student with three-year history of ADHD past treatment with Focolin, Metadate and of ADHD past treatment with Focolin, Metadate and Straterra . Currently receiving Daytrana 20 mg per Straterra . Currently receiving Daytrana 20 mg per day with a 90 percent time on task response.day with a 90 percent time on task response.
IEP: Related ServicesIEP: Related Services
School Health Services – School Health Services –
G tube feedingG tube feeding
School Nursing Services – School Nursing Services – InsulinInsulin
IEP: GoalsIEP: Goals
Measurable, reasonable, and student-Measurable, reasonable, and student-centeredcentered
Examples:Examples:
Student will be able to correlate his blood Student will be able to correlate his blood sugar readings with symptoms of high and sugar readings with symptoms of high and low blood sugars, with a 90 percent accuracy.low blood sugars, with a 90 percent accuracy.
IEP: Supplemental Aids and IEP: Supplemental Aids and ServicesServices
Supplemental aid and service Supplemental aid and service – – Aids, services, and Aids, services, and other supports provided to or on behalf of the other supports provided to or on behalf of the student student in regular education and other educational in regular education and other educational settings.settings.
Examples:Examples:
Watch with alarm to remind student to come Watch with alarm to remind student to come for for medication administration.medication administration.
Leaving class 5 minutes early to get to Leaving class 5 minutes early to get to next class safely.next class safely.
Form 1-9Form 1-9
IEP: Program ModificationIEP: Program Modificationand Supportand Support
Assistance for Assistance for school personnel school personnel on behalf of on behalf of the studentthe student
School nurse will provide one training School nurse will provide one training session, 30 minutes for all of Serena’s session, 30 minutes for all of Serena’s teachers on seizure first aid and managementteachers on seizure first aid and management
Form 1-9Form 1-9
School Nurse Documents
*good idea
IHP 504 IEP Emergency Plan
Mandated by Law No No Yes No
Professional Standards
Yes Yes No Yes
Specific Forms/Format
No Yes Yes No
Contains Student Goals
Yes Yes Yes No
Student Eligibility Requirements
No Yes Yes No
Parent Permission No* Yes Yes No*
Physician Signature
Possible Possible No Possible
* Good idea
School Nurse Documents
What do I call this document?What do I call this document?
Progress Records – At least five yearsProgress Records – At least five years--ImmunizationsImmunizations
-Lead Screening-Lead Screening Pupil Physical Health Care Record – One year after the Pupil Physical Health Care Record – One year after the
student ceases to be enrolled or written agreement with student ceases to be enrolled or written agreement with parentparent
- First Aid Log- First Aid Log- Medication Log- Medication Log
- Screening Results - Screening Results - Emergency Medical Card- Emergency Medical Card - Athletic Card- Athletic Card
- Medical release to participate in education- Medical release to participate in education
Patient Health Care Records – 5-7 yearsPatient Health Care Records – 5-7 years
- - Medical Reports from other Health Care Medical Reports from other Health Care ProviderProvider
- - Individual and Emergency Health Care PlansIndividual and Emergency Health Care Plans
- Documentation of Delegation- Documentation of Delegation
- Student Health Care Record - Student Health Care Record
- Medicaid Documentation- Medicaid Documentation
Personal RecordsPersonal Records
Questions???Questions???