School Nurse Documentation:

Ethical Considerations & Best Practices

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We all know documentation is a huge part of our job, but are we doing it in the best, most efficient way possible? If you've ever wondered about best practices, ethical considerations, or how to improve your charting skills, you won’t want to miss this!

Documentation—love it or hate it, it’s a crucial part of school nursing. Whether you’re still using paper records or transitioning to an electronic health record (EHR) system, proper documentation isn’t just about keeping track of student visits. It’s an ethical responsibility that impacts patient care, legal protection, and even your annual evaluation.

Let’s break down some of the key considerations when it comes to documentation in school nursing, including ethical challenges, timely record-keeping, and how EHRs are changing the game.

My School Nurse, Wendy DeGraffenried, has an amazing YouTube video breaking it all down. She covers:

Why timely documentation matters
Common mistakes (and how to fix them!)
Tips for navigating electronic health records (EHRs)
And so much more!

Watch it here: https://youtu.be/w-xD7pt9lH8?si=2QZVO_V7W-8d_nKR

Here's a brief written overview of what she covers in her video:

Self-Reflection: Where Do You Stand with Documentation?

Before diving in, take a moment to reflect:

What’s your current method of documentation?
Are you documenting in real time, or do you find yourself catching up hours (or days) later?
How do you handle corrections—whether on paper or in an EHR?
Have you ever experienced ethical or moral distress related to documentation?

Acknowledging these challenges is the first step toward improving your practice.

Timely Documentation: Why It Matters

Documenting student visits and interventions in a timely manner isn’t just best practice—it’s an expectation. Late entries can lead to confusion, missed details, and even impact your evaluation under the Danielson Framework (a common tool used for school nurse assessments).

Here’s what you need to know:

Aim to document by the end of the school day. If that’s not possible, make sure to note both the actual event time and the time you’re entering the record.
Consistently late documentation is considered unsatisfactory in evaluations. Even occasional delays can impact your rating.
Set a goal for yourself—whether it’s improving speed, accuracy, or reducing the number of late entries. Small improvements can make a big difference.

The EHR Transition: Your Voice Matters

Many school districts are shifting from paper documentation to electronic health records (EHRs). While this transition improves access, efficiency, and data security, it also comes with challenges.

If your district is implementing an EHR, be involved in the process! As the nurse using the system daily, you understand what works and what doesn’t. Administrators might not see the workflow challenges you face, so speak up about:

User-friendliness
Standardized naming conventions
Access for unlicensed assistive personnel (UAPs)
Security and confidentiality concerns

EHRs should support you—not create more obstacles.

Correcting Errors: What’s the Right Way?

Mistakes happen. Maybe you charted on the wrong student or entered incorrect information. The key is how you correct it:

For paper charts: Draw a single line through the error, label it as a mistake, initial it, and add the correct information. Never erase or use correction fluid.
For EHRs: Don’t delete the original entry. Instead, make an addendum explaining the error and providing the correct information. Transparency is key.

Any undocumented change can be seen as suspicious, so always follow proper correction protocols.

Delegation & UAP Documentation: Keeping It Clear

If you delegate nursing tasks to unlicensed assistive personnel (UAPs), their documentation should align with yours. Mixing documentation methods (some using paper, others using EHRs) creates confusion and gaps in care.

Make sure:

UAPs have their own login credentials for the EHR. No shared accounts or passwords!
They document only what they are responsible for—never on your behalf.
They have the right level of access to student records to complete their delegated tasks correctly.

Proper delegation and documentation protect both the nurse and the student.

Final Thoughts: Raising the Bar in School Nurse Documentation

Accurate, timely, and ethical documentation isn’t just about checking a box—it’s about providing quality student care and protecting yourself legally and professionally.

Take time to:

Evaluate your documentation habits
Set small, achievable goals for improvement
Advocate for EHR systems that work for school nurses
Ensure UAP documentation aligns with best practices

By strengthening your documentation practices, you not only improve your own efficiency but also contribute to better care for students—and that’s what school nursing is all about.

Check out these popular school nurse books!

The Importance of Documentation for School Nurses

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As a school nurse, documentation is a huge part of your day. It keeps track of your interactions with students, staff, and parents, helps maintain continuity of care, and protects your practice. Plus, good documentation makes your job a whole lot easier!

Let’s Talk Documentation (Without the Stress!)

Ah, documentation—the part of school nursing that no one really gets excited about, but we all know is absolutely essential. It’s not just about keeping records; it’s about protecting yourself, supporting your students, and keeping everything running smoothly. And if you’ve ever had that uh-oh moment trying to remember exactly what happened during a hectic school day, you already know why good documentation matters.

Why Documentation Matters

Proper documentation serves many important purposes:

Legal Protection – If a situation ever comes into question, your documentation can serve as proof that you followed the right steps and provided appropriate care. (Of course, I’m not a lawyer, so be sure to check with your school’s legal team if you have specific concerns.)
Continuity of Care – Your notes ensure that you, other health professionals, and school staff stay on the same page about a student’s health needs, history, and treatment plans.
Health Records Matter – Whether it’s asthma, allergies, diabetes, or other conditions, proper documentation helps track progress, identify patterns, and prevent emergencies.
Compliance is Key – Schools have to follow regulations like IDEA and Section 504, and your documentation plays a big role in making sure those legal boxes are checked.

What Should You Document?

School nurses should keep a detailed record of various interactions and activities. If you’re thinking, Do I really need to write all of this down?—the answer is probably yes. Here’s a general breakdown of what to include in your daily documentation:

Student Office Visits: Always document the student’s complaint, assessment information like vital signs, signs & symptoms, treatment provided, parent contact made, and how the student left your office (sent back to class, went home, etc.).
Medications Administered: If a student is given medication per doctor's orders, include: medication name, time, dosage, route, and any side effects. If something unexpected happens, make sure to document that too.
Parent/Guardian Communication: Keep records of all phone calls, emails, and meetings with parents or guardians regarding a student's health or treatment. It’s important to document what was discussed and any actions that were agreed upon.
Emergencies & Injuries: Document any emergency situations, such as an injury, a health crisis, or an incident requiring immediate medical intervention. Write down exactly what happened, how you responded, and any follow-up care. Document how the situation was handled and what steps were taken afterward.
Health Education Provided: Document any health education provided to students or staff, whether it’s a class on hand hygiene, asthma management information, or one-on-one health counseling.