Comprehensive Guide to School Health Documentation Practices

1. DOCUMENTATIONJUST 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

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

3. 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.

4. Purpose of Documentation • Communication • Legal Evidence • Research • Education • Quality Assurance • Statistics • Reimbursement

5. General Principles of Documentation • Timing • Permanence • Accuracy • Sequence

6. General Principles, cont. • Appropriateness • Completeness • Standard Terminology – NANDA and abbreviations • Legal Awareness

7. What should be avoided? • Errors in charting • Reference to district issues • Terms • Late entries

8. Laws and School Policy Family Educational Rights and Privacy Act of 1974 – FERPA Health Insurance Portability and Accountability Act of 1996 – HIPPA

9. Code of Ethics The nurse safeguards the clients’ right to privacy by judiciously protecting information of a confidential manner.

10. Types of Documentation • Direct Care • Delegation • Health Plans • 504 and IEPs

11. Direct Care SOAP Format of Charting HC- Health Concern S- Subjective O-Objective A-Assessment P-Record Plan

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

13. 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

14. IHP templates

15. 504 Definition 1. Physical and Mental Impairment 2. Record of Such Impairment 3. Limiting a Major Life Activity

16. 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.

17. 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

18. 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.

19. IEP: Related Services • School Health Services – G tube feeding • School Nursing Services – Insulin

20. 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.

21. 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

22. 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 Serena’s teachers on seizure first aid and management • Form 1-9

23. School Nurse Documents IHP 504 IEP Emergency Plan Mandated by Law No No Yes No Professional Standards Yes Yes No Yes Specific Forms/Format No Yes Yes No Contains Student Goals Yes Yes Yes No Student Eligibility Requirements No Yes Yes No Parent Permission No* Yes Yes No* Physician Signature Possible Possible No Possible School Nurse Documents * Good idea *good idea

24. 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

25. 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

26. Questions???