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
 Communication
Uses of nursing
documentation
 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 CHARACTERISTICS
2. EDUCATION AND TRAINING
3. POLICIES AND PROCEDURES
4. PROTECTION SYSTEMS
5. DOCUMENTATION ENTRIES
6. STANDARDIZED TERMINOLOGIES
High quality documentation
is:
Documentation
characteristics
 Accessible
 Legible
 Accurate, relevant, and
consistent
 Thoughtful
 Auditable
 Clear, concise, and complete
 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
 Position Statement Summary:
School Nurse
Role in
Electronic
School Health
Records
…...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
 Position statement summary:
Standardized
Nursing
Language
 …….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
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.