NCAL Inpatient
Clinical Facility / RN Preceptors
APPROVING NURSING STUDENT DOCUMENTATION IN KP HEALTHCONNECT
At the beginning of each clinical rotation, the nursing student will review all documentation prior to entry
into the medical record with either clinical faculty or KP RN preceptor. Once a student demonstrates
competence with documentation in KPHC, clinical faculty or KP RN preceptor may, on a case by case basis,
permit student to make entries independently. The unit Staff Assignment Sheet should clearly identify the
RN assigned to each patient whose care is shared by a nursing student in the event that RN has no
occasion to document in KPHC during a shift.
Approving Nursing Student Flowsheet Documentation at the Time of Documentation:
 The Nursing Student logs in to KP HealthConnect and documents on flowsheets. The clinical faculty or
RN preceptor is available to review the student’s work.
 Under the student’s login ID, the clinical faculty or RN preceptor reviews the student’s documentation
and suggests appropriate changes.
 The student makes edits as appropriate.
 With the clinical faculty or RN preceptor’s approval, the student clicks the File button to save the
documentation under the student’s ID.
Approving Nursing Student Flowsheet Documentation After the Time of Documentation:
 The Nursing Student logs in to KP HealthConnect and documents on flowsheets. The clinical faculty or
RN preceptor is not always available to review the student’s work at the time of documentation.
 The student clicks the File button to save the flowsheet documentation. Per facility policy, the student
notifies the clinical faculty or RN preceptor that a review is required.
 If faculty suggests an edit of the filed entry, the student makes any changes then re-files the new
values to save the new documentation. An Audit Trail displays any edits made and what the prior
values were, similar to lining out an entry on paper and initialing the change.
o Flowsheet documentation is filed under the student’s ID.
Approving Nursing Student Medication Administration: (refer to Regional Nursing Student
Policy for student supervision guidelines and Medication Administration parameters and scope)
The student documents in the Administration Details window of the administered medication. Depending
on the level of the student(s) in the nursing curriculum:
 Scenario 1: In the MAR Administration Details window the student may not click the Accept button
until the clinical faculty or RN preceptor reviews the documentation. The student performs any required
edits as necessary. The student indicates in the Comment field of each medication that the MAR
documentation was reviewed by the clinical faculty or RN preceptor, listing name of reviewer.
 Scenario 2: The student approved by faculty as competent to administer the specific medication
independently, may click Accept button without clinical faculty or preceptor present. After this entry
occurs, the clinical faculty or RN preceptor will document in a comment box in the MAR administration
window Note that the medication documentation has been reviewed.
 MAR administration documentation is filed under the student’s ID.
NOTE: Check with facility academic liaison/clinical educator for any local limitations based on Pharmacy
policy.
March 2016
© Kaiser Permanente 2009 | For Internal Use Only
Page 1 of 2
NCAL Inpatient
Clinical Facility / RN Preceptors
Approving a Nursing Student entry in Notes:
The Notes activity is used only when patient condition, status, response to treatment, and interventions
performed cannot be adequately described on a flowsheet.
 Student entries in the Notes activity should be restricted to changes in patient condition or events
witnessed only by the student. Other Notes entries are made by the assigned RN.
 A paper/pencil draft of any narrative note will be reviewed and approved by the clinical faculty or RN
preceptor prior to entry.
 After the clinical faculty or RN preceptor reviews and approves the note, the student enters the note
then clicks Accept to file the note in the patient’s chart.
 In an emergent situation, if a Note is not completed, student may mark it as Pended. Before reporting
off, student must complete the Note and mark it as Accepted.
o The note is filed under the student’s ID.
March 2016
© Kaiser Permanente 2009 | For Internal Use Only
Page 2 of 2