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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
rachel.gallagher@dpi.wi.gov
                 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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posted:12/21/2011
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