eschool documentation break out session pat guilday suzanne hamel
TRANSCRIPT
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Eschool documentation break out sessionPat Guilday
Suzanne Hamel
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Nursing documentation
How to make Eschool work for you
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Clear, concise, accurate and accessible documentation is an essential part of safe, quality, evidence based nursing practice.
ANA, 2010
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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,
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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
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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
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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
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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
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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
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Approved abbreviations
http://www.doe.k12.de.us/Page/2015
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Approved nursing intervention codes
Page 14 & 15
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Good Daily log habits
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When a new student enters your school
Search the student’s name
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Click on the students name
Click icon to add picture
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What’s wrong with this picture?
Display examples of poor documentation – entries on eschool
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May 10 2013
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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.