DOCUMENTATION JUST DO IT! Rachel Gallagher, R.N., A.P.N.P. Wisconsin Department of Public Instruction 125 South Webster Street Madison, WI (608)

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-ObjectiveA-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 concernNature of concern Basis of determination of disabilityBasis of determination of disability How the disability affects a major life activityHow the disability affects a major life activity Supplemental aids, services and accommodations (reasonable and comparable)Supplemental aids, services and accommodations (reasonable and comparable) Review and reassess dataReview and reassess data Participants names/titlesParticipants names/titles Case ManagerCase 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: 3 rd 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 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 *good idea IHP504IEPEmergency Plan Mandated by LawNo YesNo Professional Standards Yes NoYes Specific Forms/Format NoYes No Contains Student Goals Yes No Student Eligibility Requirements NoYes No Parent PermissionNo*Yes No* Physician Signature Possible NoPossible * Good idea School Nurse Documents

What do I call this document? 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 - Screening Results - Emergency Medical Card - Emergency Medical Card - Athletic 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???