Release date: 05/28/2021
Expiration date: 05/28/2023*
*(The module must be completed by this date to earn contact hours.)
Upon successful completion of this module, participants will receive
1.1 Nursing Continuing Professional Development Contact Hours.
Accurate, timely, and detailed documentation is essential. Documentation is needed to engage in effective communication with the student, parents, healthcare provider, and school staff. In the school setting, School Nurses are not only responsible for the documentation of nursing interventions provided to students; they must also document the education and training provided to Unlicensed Assistive Personnel (UAP). This module reviews the federal laws impacting documentation, types of documentation systems used in schools, and considerations for documentation of staff training and education.
THIS MODULE PROVIDES GUIDANCE ON THE VARIOUS ASPECTS OF HEALTH-RELATED DOCUMENTATION REQUIREMENTS IN THE SCHOOL SETTING THAT THE SCHOOL NURSE SHOULD CONSIDER. THIS MODULE DOES NOT PROVIDE INSTRUCTIONS ON HOW TO DOCUMENT. WHEN AVAILABLE, LINKS TO RESOURCES THAT CAN ASSIST THE SCHOOL NURSE WITH THE PROCESS OF DOCUMENTATION, ARE INCLUDED.
- Overview of Documentation
- Education Record
- Federal and Local Laws Impacting School Nursing Documentation
- Paper vs. Electronic Health Records
- Types of School Health Documentation
- School Policies
- Record Storage, Release, and Disposal
- Documentation of Staff Training
- Tips on Documentation
At the end of this module, the learner will be able to:
- Recall the laws impacting School Nurse documentation
- Identify which actions to take to ensure confidentiality of student records
- Recall what information should be collected and documented in a student’s health record
- Indicate what information should be documented after completing staff education and training
This continuing education program is a knowledge-based activity developed to meet the educational needs of School Nurses.
Teresa DuChateau, DNP, RN
School Health Associates
Bette Carr, MSN, RN
School Health Associates
Valerie Hon, BSN, RN
District Nurse, Safety Committee Chairperson
Portage Community School District
Faculty and Program Planner Disclosures:
The nurse planner, faculty, and reviewers disclose the absence of personal financial relationships with commercial interests relevant to this educational activity within the past 12 months.
This nursing continuing professional development activity was approved by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.