What are the basic considerations in managing school health records?
The following issues should be considered in school health records: § Nursing documentation should be accurate, objective, concise, thorough, timely, and well organized. § All entries for paper records should be legible and written in ink that can be photocopied easily (black ink is recommended). § The date and exact time should be included with each entry. § Documentation should include any nursing action taken in response to a student’s problem. § Assessment data should include significant findings, both positive and negative. § All records, progress notes, individualized health care plans, and flow charts should be kept current. The current individualized healthcare plan should be marked as “part of the permanent health record”. Standardized healthcare plans are acceptable as long as they are individualized to each student’s condition and needs. § Documentation should include only essential information; precise measurements, correct spelling, and standard abbreviations should be use
