Legal Issues 101: Documentation and School Records.

Q3 Medicine NASN school nurse (Print) Pub Date : 2024-03-01 Epub Date: 2023-07-13 DOI:10.1177/1942602X231186095
Eileen Moss
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Abstract

This article is part of a series of articles titled "Legal Issues 101" addressing some common questions and misconceptions around the law and school health. Nursing documentation, a recording of interactions between a nurse and a patient, is a vital part of nursing care. Timely, thorough documentation allows for patient safety, risk reduction, continuity of care, and the availability of data for work process analysis. In the school setting, nursing documentation encompasses a record of student treatment in the health office as well as communication with parents, school team members, and healthcare providers. Student health records are intersected by educational and health privacy laws, which can create confusion around record management. The purpose of this article is to clarify frequently asked questions related to health office documentation.

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法律问题 101:文件和学校记录。
本文是 "法律问题 101 "系列文章的一部分,探讨了一些有关法律和学校卫生的常见问题和误解。护理文件是护士与病人之间互动的记录,是护理工作的重要组成部分。及时、详尽的记录可以保障患者安全、降低风险、保持护理的连续性,并为工作流程分析提供数据。在学校环境中,护理文件包括卫生室的学生治疗记录以及与家长、学校团队成员和医疗服务提供者的沟通。学生健康记录与教育和健康隐私法相互交叉,可能会造成记录管理方面的混乱。本文旨在澄清与医务室记录相关的常见问题。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
NASN school nurse (Print)
NASN school nurse (Print) Medicine-Medicine (all)
CiteScore
0.60
自引率
0.00%
发文量
105
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