Throughout your school nursing career, you’ve probably often wondered what do I need to include, or exclude, in my documentation? In the upcoming session, “Surefire Documentation Techniques: What Every School Nurse Needs to Know” on June 30, 8:15 – 9:45 a.m. at NASN2024, you’ll get a chance to explore documentation in depth.
We’ll discuss what’s relevant to include in your documentation, and what is just filler. This is especially important when you consider that whatever you write, or type, into the medical record could be read in open court later. If your charting is less than stellar, it goes to your credibility. And, once you’ve lost your credibility, it’s hard to get it back.
Timing is everything, as Shakespeare once said. This is easily applied to your documentation. When do you actually record whatever it is you did for a student? Is it at or near the time you performed the task, which is contemporaneous charting, or is it at a later date, which is known as summary charting. Frankly, contemporaneous charting is the preferred because it’s more credible.
Alas, we need to consider your going up the chain of command. You’ll wish you did if the outcome is not favorable. Knowing this in advance is all the more reason that you need to know with whom to discuss your situation well in advance of it actually happening. When you have a plan, it makes it infinitely easier to execute on your plan rather than just winging it.
These are just some of the areas we’ll explore together with real world suggestions for conquering them. Come to find out much more.