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     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

   What is documentation?
   Purpose
   General Principles
   Laws and School Policy
   Types of documentation
   Type of records
 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
       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

 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
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 –
                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
 Supplemental aid and service – Aids, services, and
  other supports provided to or on behalf of the
  student in regular education and other educational
 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

 Specific               No           Yes          Yes         No

 Contains Student       Yes          Yes          Yes         No

 Student Eligibility    No           Yes          Yes         No

 Parent Permission      No*          Yes          Yes         No*

 Physician              Possible     Possible     No          Possible

* Good idea
    What do I call this document?
 Progress Records – At least five years
      -Lead Screening
 Pupil Physical Health Care Record – One year after the
  student ceases to be enrolled or written agreement with
       - 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
     - Individual and Emergency Health Care Plans
     - Documentation of Delegation
     - Student Health Care Record
     - Medicaid Documentation
 Personal Records

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