NURSING DOCUMENTATION

Documentation in Nursing School

Abstract

School nurses are aware of a lot of intimate information about students with whom they work. The increase in the number of children in schools with health and learning difficulties has translated into more than traditional projection and immunization information records. A health of a student complex web of laws and regulations defining practice responsibilities and rights of parents, students, school health personnel and school personnel in creating, updating, maintenance, control, access and disclosure of health records of students.

This document discusses the responsibilities of school personnel in creating health records about a student, maintaining records, and discloses or share the information contained in these records. It also discusses the rights of parents and students access to these records and their right to control the release of such records.

Table of Contents

INTRODUCTION4

CURRENT LEGISLATIONS5

IMPLICATION OF SCHOOL NURSE PRACTICE8

No Child Left Behind8

LITERATURE REVIEW9

What is a Record?9

Who creates the School Health Records?10

Maintenance and Preservation Logs11

Who else can access?12

DOCUMENTS AND THE ROLE OF SCHOOL NURSE13

DISCUSSIONS OF THE FINDINGS13

Health Care Plans14

Electronic records?14

CONCLUSION15

Documentation in School Nursing

Introduction

Need for a school to document and share health information of students must be considered against the student's right to confidentiality of sensitive services or improper disclosure of personal information and the parents and the student's right to know what which is in the record of a student to access it for inspection or correction, and to control the disclosure of such information (Lee, 2005).

School nurses can be the authors and / or custodians of many formal records, health law for this, such as the Individualized Family Service Plan (IFSP), Individualized Health Plans (IHPS), Emergency Plans (IEP) etc.

School nurses are part of a team and the realities of a school day means that a number of scenarios may arise in relation to student health information. What health information is a school nurse can collect? What health information is a school nurse required to maintain in a formal document? What information from this record is the school nurse's ability to publish and in what circumstances? The answers to these questions are complicated by the fact that school personnel often others may be involved in creating, updating, maintenance and storage of health records, and respond to requests for access to those records (Birkholz, 2008).

Current Legislations

This section briefly describes the relevant legislation and then passed through the "life stages" of a record, with the requirements of each law in particular. Privacy, access and disclosure.

Family Educational Rights and Privacy Act (FERPA)

Educational Rights and Privacy Act (FERPA, sometimes called the "Buckley Amendment") is a federal law designed to protect the privacy of education records of students are maintained by a school. School health records are considered part of the student record. The law applies to all schools that receive federal funds from the Department of Education United States. Basically, the law gives parents the right to inspect and review educational records of their children, to correct errors or inaccuracies in the records, and consent to the disclosure of such ...