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Importance of documenting health records

Redio Mase

New Member
Documentation of health information is an expectation of professional school nursing practice according to the Scope and Standard of School Nursing Practice and may be required by state health statutes. School nurses work with a variety of health information including immunization records, screening records, progress notes, physician orders, physical examination records, medication and treatment logs, reports of serious injury individualized healthcare plans, emergency healthcare plans, third party medical records, consent forms, the management of students’ chronic health condition Medicaid, and other insurance billing forms, and flow charts. Health information in any form must be confidential, secure, accessible only by authorized staff, and protected from loss, alteration, or destruction. As an educational record, school health records must be transferable to new school sites when a student progresses to other buildings within a district or moves outside of the district. Society and the United States healthcare system is transitioning from paper to electronic technology. The Centers for Medicare and Medicaid Services (CMS) actively promotes EHRs with a goal of improving health care; school nurses share this same goal. EHRs improve the efficiency and the use of school health data such as absenteeism to determine appropriate interventions. EHRs support the ability to make the right information available to the right provider at the right time to benefit student care.

School health records provide the mechanism for a school nurse to communicate information to students, families, the school multidisciplinary team, emergency personnel, other healthcare providers, and school nurse substitutes. Data from school health records can show evidence of student health problems that should be addressed. The large caseloads and volumes of longitudinal student information collected by school nurses result in a quantity of data that is not readily managed by paper processes. Electronic documentation systems allow for efficient data management processes including the documentation, reporting, and analysis of student health data. Electronic data management systems also allow for the aggregation of data from multiple sources if the data elements are standardized across systems. The ability to build a database requires the EHRs to be able to speak the same language. Data in systems that use standardized languages and are interoperable across a variety of settings will allow the expansion of evidence to determine nursing interventions that support student academic success