Documentation
NYS nurses must keep accurate medical records. Rules of the Board of Regents section 29.2 (a)(3) states: unprofessional conduct shall include failing to maintain a record for each patient that accurately reflects the evaluation and treatment of the patient. In schools, school nurse’s patients are the students and those students’ health records maintained by the school are confidential in compliance with Education Law 2-d and the Family Rights and Privacy Act (FERPA).
We strongly recommend:
- Speaking to your district/school’s legal counsel regarding health office documentation.
- Creating a documentation system across your district to ensure continuity.
- Including documentation as a part of the school nurse's orientation.
Nursing documentation occurs throughout nursing practice in all settings. Documentation should provide information on the nurse’s assessment (both subjective and objective findings), the nursing care provided (nursing interventions) and the effectiveness (outcomes). Additionally, any communication to others should be documented.
As school nurses implement interventions that promote health and safety, they need to carefully consider how the outcomes of these interventions can be measured and evaluated, and how they affect the well-being and academic success of students.
ADPIE and SOAPIE are two common documentation formats utilized by nurses. SBAR is a common communication technique, which can be used when documenting a communication. ADPIE, SOAPIE, and SBAR, when filled accurately and systematically, can also protect nurses legally if there is a complaint or lawsuit related to patient care.
Click here for detailed information on ADPIE, SOAPIE, and SBAR
Resources
American Health Information Management Association (AHIMA) Ethical Standards for Clinical Documentation Integrity
Provides ethical guidelines based on the professional values and ethical principles to which healthcare professionals aspire and by which their actions can be judged.
Section 7.6 Clinical documentation integrity professionals shall not add, delete, or alter health record documentation; this includes patient problem lists.
Kaiser Permanente - Patient Safety - SBAR
A structured communication technique designed to convey a great deal of information in a succinct and brief manner.
Lippincott Nursing Center - Nursing Documentation
Nursing documentation provides a full account of patient care to create a record of services.
Nursing Education - Nurse Insights: What Are the Best Practices for Nursing Documentation?
The Royal Children's Hospital Melbourne: Nursing Documentation Principles and Guidelines (rch.org.au) Provides Information on Nursing Documentation Principals
National Association of School Nursing (NASN)
Legal Issues 101 - Documentation and School Records
In the school setting, nursing documentation encompasses a record of student treatment in the health office as well as communication with parents, school team members, and healthcare providers.
Position Statement - Electronic Health Record
It is the position of the National Association of School Nurses that electronic health records software platforms (EHRs) are essential tools for all registered professional school nurses.
Unlocking the Power of School Nursing Documentation
This article demonstrates the utility of the nursing process for improving the quality of documentation and provides examples of how to use nursing documentation formats.
See Also:
Page Created 10/04/24