Documentation
To ensure accurate records, this task must be completed by the end of the day for all health office visits.
What is entering health office visits into Infinite Campus?
This legal term refers to the failure to take proper care in doing something, resulting in harm to another person.
What is negligence?
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?
What is an addendum in the previous health office visit note and/or where is the Health Contact Log?
Arizona legislature has strict documentation guidelines for school nurses.
What is false?
"I have a really bad headache, and it feels like it's throbbing".
What is subjective?
These shorthand terms are used in school nursing records and are listed under Health Services Resources.
What are approved abbreviations for school nursing documentation?
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?
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?
It is ok to share information about a student on social media as long as you don't use their name.
What is false?
"My stomach hurts, and I feel like I might throw up".
What is subjective?
Examples of this type of documentation are: "I have a really bad headache, and it feels like it's throbbing". "I feel dizzy when I stand up". “My stomach hurts, and I feel like I might throw up". "I couldn't sleep last night because I was worried about my test today".
What is subjective data?
These are documents, records, or physical objects presented as evidence during a legal proceeding.
What are exhibits?
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?
Incomplete or inaccurate documentation is a common pitfall in school nursing documentation.
What is true?
!!WILD CARD!!
This Health Services team member once worked alongside the Count on Sesame Street—and she’s been counting blood pressures, prescriptions, and PTO days ever since!
Who is Christine?
!!WILD CARD!!
This Health Services team member never met a radio contest she didn’t like — or a busy signal she couldn’t conquer — earning her a meet & greet with the artist Pink!
Who is Lynn?
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?
!!WILD CARD!!
This Health Services team member once went undercover for the DEA wearing a wire—so if she leans in close, it might not just be for training purposes.
Who is Emily?
It is best practice to document after you have performed a task.
What is true?
Student is pale, HR 82, BP 105/65, T 98.6
What is objective?
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?
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?
After a student is brought to the health office by staff following a safety hold, the nurse notes a scratch on the right forearm and redness. The intervention drop-down should include this documentation option.
What is the Behavior Tracking Form?
!!WILD CARD!!
When her dream of international figure skating glory didn’t quite stick the landing, this Health Services team member hung up her skates—but not her ambition—and became a nurse instead.
Who is Angie?
!!WILD CARD!!
After taking motorcycle lessons earning her M class license, this Health Services team member discovered that “wind in her hair” also meant “bugs in her teeth.”
Who is Lisa?