Eschool documentation break out sessionPat Guilday

Suzanne Hamel

Nursing documentation

How to make Eschool work for you

Clear, concise, accurate and accessible documentation is an essential part of safe, quality, evidence based nursing practice.

ANA, 2010

Uses of nursing documentation

Communication Assessments Clinical problems Patient(student)

clinical parameters Patient (student)

responses and outcomes

Plans of care Communication with

the patient (student), families, other healthcare providers,

Principles of Nursing documentation Documentation does more than just tell a story.

The American Nurses Association identifies documentation as an essential component of nursing practice. They have identified these areas of focus:

1. DOCUMENTATION CHARACTERISTICS2. EDUCATION AND TRAINING3. POLICIES AND PROCEDURES4. PROTECTION SYSTEMS5. DOCUMENTATION ENTRIES6. STANDARDIZED TERMINOLOGIES

Documentationcharacteristics

High quality documentation is:

Accessible

Accurate, relevant, and consistent

Auditable

Clear, concise, and complete

Legible

Thoughtful

Timely

Reflective of the nursing process

Retrievable on a permanent basis

DOCUMENTATION ENTRIES

Accurate, valid, and complete

Authenticated – the information is truthful, the author is identified, and nothing has been added or inserted

Date and time stamped by the person who created the entry

Uses standardized terminology, including acronyms and symbols

STANDARDIZED TERMINOLOGIES

Permit data to be aggregated and analyzed

Include terms that are used to describe the planning, delivery, and evaluation of nursing care in diverse settings

School Nurse Role in Electronic School Health Records

Position Statement Summary:

…...Electronic health records (EHRs) are essential for the registered professional school nurse to provide efficient and effective care in the school and monitor the health of the entire student population.

Position statement NASN – adopted January 2014

Standardized Nursing Language

Position statement summary:

…….Standardized nursing languages (SNL) are essential communication tools for registered professional school nurses. ….SNL provide a common language, contribute to quality of care, enable continuity of care, and support research (Denehy, 2010). SNL enable communication about the contribution of professional school nursing practice to health and academic success of students.

Position statement NASN – revised June, 2012

Approved abbreviations

http://www.doe.k12.de.us/Page/2015

Approved nursing intervention codes

Page 14 & 15

Good Daily log habits

When a new student enters your school

Search the student’s name

Click on the students name

Click icon to add picture

What’s wrong with this picture?

Display examples of poor documentation – entries on eschool

May 10 2013

American Nurses Association & National Association of School Nurses. (2011). School nursing: Scope and standards of practice. (2nd ed.). Silver Springs, MD: Nursebooks.org

American Nurses Association. (2010). Principles for Nursing Documentation. Silver Springs, MD.

Denehy, J. (2003). Documentation Dilemma: what to record and why. JOSN 19(4)187-190.

Johnson, K.H.,Bergren, M.D. & Westbrook, L.O. (2012). The promise of standardized data collection: school health variables identified by states. JOSN 28(2) 95-107.

Johnson,K.H. & Guthrie, S. (2012).Harnessing the power of student health data. NASN School Nurse 27(1), 27-33.

National Association of School Nurses, (2014) School nurse role in electronic health records (Position Statement). Retrieved from http://www.nasn.org/PositionPapersandReports.

National Association of School Nurses (2012) Standardized nursing language (Position Statement). Retrieved from http://www.nasn.org/PositionPapersandReports.