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???