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DOCUMENTATION JUST DO IT! Rachel Gallagher, R.N., A.P.N.P. Wisconsin Department of Public Instruction 125 South Webster Street Madison, WI 53707 (608) 266-8857 email@example.com Overview What is documentation? Purpose General Principles Laws and School Policy Types of documentation Type of records Documentation Written evidence of the interaction between and among students, families, school staff, health care professionals, regarding care, training, consultation, student education, and the results or response to the intervention. Written record of nursing process to deliver care. Purpose of Documentation Communication Legal Evidence Research Education Quality Assurance Statistics Reimbursement General Principles of Documentation Timing Permanence Accuracy Sequence General Principles, cont. Appropriateness Completeness Standard Terminology – NANDA and abbreviations Legal Awareness What should be avoided? Errors in charting Reference to district issues Terms Late entries Laws and School Policy Family Educational Rights and Privacy Act of 1974 – FERPA Health Insurance Portability and Accountability Act of 1996 – HIPPA Code of Ethics The nurse safeguards the clients’ right to privacy by judiciously protecting information of a confidential manner. Types of Documentation Direct Care Delegation Health Plans 504 and IEPs Direct Care SOAP Format of Charting HC- Health Concern S- Subjective O-Objective A-Assessment P-Record Plan Delegation Documentation Date and time of training Willingness to assume responsibility Competency checklist of skills Contact information for questions or changes in health status. Individual and Emergency Health Care Plans IHP – Addresses actual or potential responses to a student to a health care condition. Carried out in part by the nurse. ECP – Deals with a specific potential medical emergency. Can be carried out exclusively by other staff through training and delegation. Step by step in nature. Use Nursing Process IHP templates 504 Definition 1. Physical and Mental Impairment 2. Record of Such Impairment 3. Limiting a Major Life Activity 504 Plan Documentation Many variations in plan. Typically include: • Nature of concern • Basis of determination of disability • How the disability affects a major life activity • Supplemental aids, services and accommodations (reasonable and comparable) • Review and reassess data • Participants names/titles • Case Manager IHP can become a variation of a 504 Plan or be utilized to write a 504 plan. Individualized Education Plan Nursing Documentation PLAEFP – Present Levels of Academic and Functional Performance Additional Testing – Observations, rating scales, time on task studies, screenings. Related Services ****** Goals Supplemental Aids and Services Program Modifications IEP: PLAEFP PLAEFP – Present Levels of Academic and Functional Performance Brief statement of health diagnosis, medications, health needs at school and concerns that impact the ability to learn. Example: 3rd grade student with three-year history of ADHD past treatment with Focolin, Metadate and Straterra . Currently receiving Daytrana 20 mg per day with a 90 percent time on task response. IEP: Related Services School Health Services – G tube feeding School Nursing Services – Insulin IEP: Goals Measurable, reasonable, and student-centered Examples: Student will be able to correlate his blood sugar readings with symptoms of high and low blood sugars, with a 90 percent accuracy. IEP: Supplemental Aids and Services Supplemental aid and service – Aids, services, and other supports provided to or on behalf of the student in regular education and other educational settings. Examples: Watch with alarm to remind student to come for medication administration. Leaving class 5 minutes early to get to next class safely. Form 1-9 IEP: Program Modification and Support Assistance for school personnel on behalf of the student School nurse will provide one training session, 30 minutes for all of Serena’s teachers on seizure first aid and management Form 1-9 School Nurse Documents IHP 504 IEP Emergency Plan Mandated by Law No No Yes No Professional Yes Yes No Yes Standards Specific No Yes Yes No Forms/Format Contains Student Yes Yes Yes No Goals Student Eligibility No Yes Yes No Requirements Parent Permission No* Yes Yes No* Physician Possible Possible No Possible Signature * Good idea What do I call this document? Progress Records – At least five years -Immunizations -Lead Screening Pupil Physical Health Care Record – One year after the student ceases to be enrolled or written agreement with parent - First Aid Log - Medication Log - Screening Results - Emergency Medical Card - Athletic Card - Medical release to participate in education Patient Health Care Records – 5-7 years - Medical Reports from other Health Care Provider - Individual and Emergency Health Care Plans - Documentation of Delegation - Student Health Care Record - Medicaid Documentation Personal Records Questions???
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