School day documentation

Posted

I attend school with a student with a seizure disorder. There are no tubes, diapers, wheelchairs, no meds to give. I’m not sure what to write in my notes. My role is to monitor for seizures and administer emergency medication if needed. So basically I sit in the back of the classroom and just watch. I write that she is attentive and cooperative with school work.  No seizure activity. I don’t think specifics about her class work is medically necessary to document. Any ideas? 

caliotter3

38,332 Posts

Each hour make an entry that there are no signs of discomfort or seizure activity, perhaps a remark about attentiveness or cooperation. Do this for awhile to see if it flies versus the one catch-all sentence at the end of the school day/shift, or ask your clinical supervisor if they want more. I have found, particularly lately, that one could write that the grass is blue and the sky is green and the supervisors/documentation reviewers wouldn’t say boo because they don’t bother to look at documentation and they don’t care. I think hourly or even every two hour entries would at least show you are trying to document correctly.

amoLucia

Specializes in retired LTC. 7,641 Posts

Bathroom activity? Lunch? Friendly with peers?

LeChien, BSN, RN

Specializes in Emergency Nursing, Pediatrics. Has 10 years experience. 277 Posts

I just wanted to add, you can also chart that pt is alert and oriented, engaged with peers/teachers, respirations even and unlabored, skin warm and dry, cap refill, etc.