1. Eschool documentation break out session
Pat Guilday
Suzanne Hamel

2. Nursing documentation
How to make Eschool work for you

3. Clear, concise, accurate and accessible documentation is an essential part of safe, quality, evidence based nursing practice. ANA, 2010

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Approved abbreviations

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

12. Good Daily log habits

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

14. Click on the students name

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

23. May

26. 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)
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)
Johnson,K.H. & Guthrie, S. (2012).Harnessing the power of student health data. NASN School Nurse 27(1),
National Association of School Nurses, (2014) School nurse role in electronic health records (Position Statement). Retrieved from
National Association of School Nurses (2012) Standardized nursing language (Position Statement). Retrieved from