Eschool documentation break out session Pat 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, Uses of nursing documentation

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 CHARACTERISTICS 2. EDUCATION AND TRAINING 3. POLICIES AND PROCEDURES 4. PROTECTION SYSTEMS 5. DOCUMENTATION ENTRIES 6. STANDARDIZED TERMINOLOGIES

Documentation characteristics 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 STANDARDIZED TERMINOLOGIES 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 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 School Nurse Role in Electronic School Health Records

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 Standardized Nursing Language

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

Approved nursing intervention codes Page 14 & 15 Approved nursing intervention codes

Good Daily log habits

When a new student enters your school Search the student’s name

Click on the students name

What’s wrong with this picture? Display examples of poor documentation – entries on eschool What’s wrong with this picture?

May 10 2013

American Nurses Association & National Association of School Nurses 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.