Documentation
Take it to court! (legal terms in school nursing)
Document where?
True or False?
100

To ensure accurate records, this task must be completed by the end of the day for all health office visits.

What is entering visits into Infinite Campus?

100

This legal term refers to the failure to take proper care in doing something, resulting in harm to another person.

What is negligence?

100

Student with history of asthma c/o difficulty breathing. O2 sat 87%, P 114, call placed to parent who lives 3 min away. Parent picks up, takes student to emergency department. Parent calls the next morning to report back the series of events that occurred at the ED including admission to pediatric hospital. Per CUSD policy, this type of documentation is required where in Infinite Campus?

Where is Health Contact Log and/or as an addendum in the previous health office visit note?

100

Arizona legislature has strict documentation guidelines for school nurses. 

What is false?

200

These shorthand terms are used in school nursing records and are listed under Health Services Resources.

What are approved abbreviations for school nursing documentation?

200

This legal document, often used in legal proceedings involving student records, requires a person to appear in court under sworn testament about facts/evidence.

What is a subpoena?

200

Student reports hit to head at soccer practice Sunday afternoon, presenting with dizziness, general fatigue, right pupil nonreactive to light. Call placed to mom to recommend medical evaluation. Per CUSD policy, this type of documentation is required in infinite campus.

What is health office visit note?

200

It is ok to share information about a student on social media as long as you don't use their name.

What is false?

300

These are documents, records, or physical objects presented as evidence during a legal proceeding.

What are exhibits?

300

Suddenly your school district has changed their website, and you find yourself unable to find a simple health document, so you reference this place that your fearless leader has created.

What is Health Services Home SharePoint?

300

Suddenly your school district has changed their website, and you find yourself unable to find a simple health document, so you reference this place that your fearless leader has created.

What is "Health Services Home" SharePoint?

400

Two common documentation pitfalls in school nursing include these issues.

What are falsified records or failure to meet regulatory standards, or incomplete/inaccurate documentation?

400

This type of subpoena requires a person to bring documents, records, or other evidence on or off the record, including texts, instant messaging and emails to court or a legal proceeding.

What is a subpoena duces tecum?

400

It is best practice to document after you have performed a task.

What is true?

500

This is considered your best legal defense as a school nurse and provides a detailed account of care given.

What is accurate documentation or the medical record?

500

In a civil case involving this type of professional misconduct, the burden of proof is 51% or the preponderance of the evidence.

What is nursing malpractice?