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) 266-8857rachel.gallagher@dpi.wi.govrachel.gallagher@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???