Let s Talk Documentation!

Transcription

1 Let s Talk Documentation! Date January 22, 2014 February 5, 2014 February 19, 2014 March 5, 2014 Webinar Title Individualized Healthcare Plans Emergency Care Plans Using Position Documents HIPAA and FERPA Host: Margaret Cellucci, NASN Director of Communications Speaker: Sally Schoessler, Director of Nursing Education 1

2 Where to Begin? Commonly referred to as an IHP The document that combines all of the student s healthcare needs into one document for managing the health needs of the student at school (Zimmerman, 2013) (Silkworth, Arnold, Harrigan& Zaiger, 2005) Acute care Illness puts the family in crisis Chronic care Illness is (or is becoming) part of normal family lifestyle Hospital School 2

3 Defines Student care validates the nurse s role in the school Delegation of care Describes Communication tool between nurses and staff as appropriate Delivers Framework for intentional care of the whole student Support for student achievement (Silkworth, Arnold, Harrigan& Zaiger, 2005) Demonstrates the Standards of School Nursing Practice Documents the Nursing Process Provides Legal Documentation Clarifies Clinical Practice Provides evidence of school nursing effectiveness (data) Provides a foundation for health information and activities IEPs, 504 Plans (NASN, 2013) Nursing Diagnosis The Foundation of Care Plan Development 3

4 North American Nursing Diagnosis Association: A nursing diagnosis is a clinical judgment about an individual, family or community response to actual or potential health problems/life processes. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (Herdman, 2012) NANDA Functional Health Patterns Framework: 1. Health Perception/Management 7. Self-Perception/Concept Pattern 2. Nutrition/Metabolic Pattern 8. Role/Relationship 3. Elimination 9. Sexuality/Reproductive 4. Activity/Exercise 10. Coping/Stress Tolerance 5. Sleep/Rest 11. Value/Belief Pattern 6. Cognitive/Perceptual Pattern NANDA - (Herdman, 2012) Differs from a medical diagnosis: Focus of nursing care is the whole person or person s achievement of well being Guide nursing care for the achievement of positive health outcomes Interventions to promote, protect and restore health (Herdman, 2012) 4

5 Writing Your Care Plan Meeting Student Needs Prioritize student need Start with students that are medically fragile or who may experience a health crisis at school Students whose healthcare needs affect or have the potential to affect safe and optimal school attendance and academic performance Students who qualify for an IEP or 504 Plan Use your clinical nursing judgment when prioritizing who you will write a care plan for (Zimmerman, 2013) A nursing responsibility to write and implement the plan of care Based on standards of care Evaluation of plan of care at least yearly and as changes in health status occur Determine need for revision Collect data Show evidence of expected student outcomes (NASN, 2013) 5

6 Nursing Assessment Need Baseline Data A1C, Peak flow measurements, etc. Assess for social determinants and cultural needs Nursing Diagnosis Prioritizing Diagnoses Practical and comprehensive Goals Use SMART format be sure they are measurable Nursing Interventions Evaluation / Expected Outcomes (using data) (Silkworth, Arnold, Harrigan& Zaiger, 2005) Can develop IHP Packets Could include: Health assessment sheet specific questions relevant to child s condition (i.e. asthma, diabetes) Letter to the parent (explaining process, getting signed permission to speak to provider) Collaboration with parent / guardian Teaching sheets about illness or treatment regimens IHP form or template (Zimmerman, 2013) 6

7 Position Statement from NASN Individualized Healthcare Plans Books: School Nursing: A Comprehensive Text (2013) F. A. Davis Company Managing Diabetes at School: Tools for the School Nurse (contains 3 IHPs) available with CD to print IHPs Need to develop a district policy or procedure for IHP storage and access Recommendations: Not in the cumulative educational record Stored in cumulative health record Part of Permanent Health Record Special Education special considerations Allows for accountability Enables student to fully access educational program Communication Identifies health outcomes Outlines nursing interventions Provides for continuity of care Administrative Purpose Clinical Purpose 7

8 Write at least one more care plan than you did last year Even if it s your first one! Every student doesn t need an IHP Work with parents and students Keep the plan concise and manageable Write only what you can do If you write it, you re responsible to do it! Enjoy the process! Herdman, T. H. (2012). (Ed.)North American Nursing Diagnosis Association International. Nursing diagnoses: Definitions and classifications: Oxford: Wiley-Blackwell. Silkworth, C., Arnold, M., Harrigan, J., & Zaiger, D. (2005). Individualized Healthcare Plans for the School Nurse. North Branch, MN: SunRise River Press. National Association of School Nurses. (2013). Position statement: Individualized healthcare plans, the role of the school nurse. Retrieved from NASNPositionStatementsFullView/tabid/462/ArticleId/32/Individ ualized-healthcare-plans-the-role-of-the-school-nurse- Revised-June-2013 Zimmerman, B. (2013). Student health and education plans. In J. Selekman (Ed.), School nursing: A comprehensive text. Philadelphia: F. A. Davis Company. Speaker: Sally Schoessler, MSEd, BSN, RN NASN Director of Nursing Education sschoessler@nasn.org 8