The electronic health record (EHR) is a confidential and legal document. It provides a form of communication for documenting activities/conditions relevant to the child's health. It is important to remember to write down or record what you observe and what you do. This documentation is admissible in a court of law, meaning anything you write or enter into the electronic record is considered to be true. If you do not record something that you did, it is assumed that it was not done. There are some general guidelines for documentation that everyone must follow:

Confidential or sensitive information (i.e., student discussing suicidal thoughts, pregnancy, etc.) is not to be recorded on the EHR Health program. This information should be kept in a confidential locked file. This file will serve as a record indicating that the situation has been addressed as well as protect sensitive information. If in doubt, contact your principal and school RN for guidance on what information should be documented in the confidential file. Also, consult your principal for file storage procedures in your school.
Use day, month, year, time of day, and your signature (initials are OK if your signature is identified on the page with your initials).
Never erase or use liquid correction fluid ("white out").
Use authorized abbreviations (see Medical Abbreviations in Forms Section).
Records must be entered daily.
Describe what is seen or heard, but make no judgments.
No vague phrases.
Don't write assumptions.
Do not accuse, blame, or characterize anyone in your documentation.
Never refer to an accident report that has been filed.
Never write or enter into the electronic record care or observations ahead of time.
Don't leave blank spaces on forms.
Correctly identify late entries (for manual documentation).
Correct mistaken entries properly.

Observation

When interacting with the student, use all of your senses to evaluate the situation.

Look Listen Feel Smell

There are two types of observation:

Subjective observation cannot be seen. They are ideas, thoughts, or opinions about the student. If you cannot see it, hear it, or smell it, it is a subjective observation. (The student complains of a headache - you cannot see it.)

Objective observations can be seen. If you see, feel, hear, or smell it, it is an objective observation. (The student has a cut - you can see it.)

Sarasota County Schools

Student Health Records and Documentation

The Student Cumulative Health Record

Documentation

Health Room Visit Documentation

Student Accident Report

Student Injury Report

Health Room End of Year Checklist

Medical Abbreviations