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Tools & ResourcesDocumentation in School Health    October 1, 2014
 

Documentation in School Health

Background

The records that school nurses keep in their daily care of over 95% of US school-aged children provide an important window into child health in our nation.  Records are being kept on students who are well (screening, immunization, and episodic health room care); and students with chronic health conditions (emergency care planning; daily treatment and response data for students with conditions such as asthma; severe allergies; seizure disorders; and Type I Diabetes).  School nurses also maintain health records on students who fall outside the typical health care provider systems and whose only source of care may be the school nurse.

Students from the most diverse and complex clinical settings come to school and require care that must be coordinated with acute care records in order to assure efficient, effective care, making schools an effective partner for Accountable Care Organizations.
 
In addition, school health data provides the potential to determine the most effective interventions to support the well being of children.  There is potential to analyze this data at both the individual and population level to understand the links between health and education as well as the links between health interventions and outcomes.

NASN’s Informatics Advisory Committee is working to develop standardized coding systems to support interoperability of school health records with other care systems.

NASN Resources

National Association of School Nurses (2012). Position Statement. Standardized nursing languages.  Silver Spring, MD: Author.

National Association of School Nurses (2004). Issue Brief. Privacy standards for student health records.  Silver Spring, MD: Author.

National Association of School Nurses (2004). Issue Brief. School health records.  Silver Spring, MD: Author.

Johnson, K. H., Bergren, M. D., & Westbrook, L. O. (2012). The promise of standardized data collection: School health variables identified by states. Journal of School Nursing, 28(2), 95-107.
doi:10.1177/1059840511426434

Johnson, K. H., & Bergren, M. D. (2011). Meaningful use of school health data. The Journal of School Nursing, 27 102-110. doi:10.1177/1059840510391095

Additional resources 

Right to Access Memo
This is the Office for Civil Rights memo which clearly states that you have a right to “Ask to see and get a copy of your health record…” and “…Get a copy of your record in the way that
you want…”

Page Published March 2013

 
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