DOCUMENTATION JUST DO IT!

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DOCUMENTATIONJUST DO IT!

• Rachel Gallagher, R.N., A.P.N.P.
• Wisconsin Department of Public Instruction
• 125 South Webster Street
• Madison, WI 53707
• [phone]
• rachel.gallagher_at_dpi.wi.gov

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Overview

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

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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.

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Purpose of Documentation

• Communication
• Legal Evidence
• Research
• Education
• Quality Assurance
• Statistics
• Reimbursement

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General Principles of Documentation

• Timing
• Permanence
• Accuracy
• Sequence

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General Principles, cont.

• Appropriateness
• Completeness
• Standard Terminology NANDA and abbreviations
• Legal Awareness

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What should be avoided?

• Errors in charting
• Reference to district issues
• Terms
• Late entries

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Laws and School Policy

• Family Educational Rights and Privacy Act of 1974
  FERPA
• Health Insurance Portability and Accountability
  Act of 1996 HIPPA

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Code of Ethics

• The nurse safeguards the clients right to
  privacy by judiciously protecting information of
  a confidential manner.

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Types of Documentation

• Direct Care
• Delegation
• Health Plans
• 504 and IEPs

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Direct Care

• SOAP Format of Charting
• HC- Health Concern
• S- Subjective
• O-Objective
• A-Assessment
• P-Record Plan

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Delegation Documentation

• Date and time of training
• Willingness to assume responsibility
• Competency checklist of skills
• Contact information for questions or changes in
  health status.

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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

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IHP templates
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504 Definition

• 1. Physical and Mental Impairment
• 2. Record of Such Impairment
• 3. Limiting a Major Life Activity

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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.

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Individualized Education PlanNursing
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

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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.

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IEP Related Services

• School Health Services
• G tube feeding
• School Nursing Services
• Insulin

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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.

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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

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IEP Program Modificationand Support

• Assistance for school personnel on behalf of the
  student
• School nurse will provide one training session,
  30 minutes for all of Serenas teachers on
  seizure first aid and management
• Form 1-9

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School Nurse Documents  
School Nurse Documents  
  Good idea
  good idea
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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

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• 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

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• Questions???