North Carolina School Health Program Manual Section C, School Nursing Practice, Chapter 6,
Documentation
2 NC DCFW/SACHU 3/2024
Medical Records from outside providers that have been obtained by parental consent, should be
stored in the individual student health record. Pertinent records should be maintained by the
school and become part of the education record, governed by the Family Educational Rights and
Privacy Act (FERPA). Only portions needed to support student health and safety in the school
should be retained. When information is sent from an outside provider that is not needed for this
purpose, it should be immediately destroyed or returned to the provider. A release of information
should explicitly list the types of information being requested and indicate when a summary is
sufficient. The purpose of the request should be clear. Health information generated by schools
for data collection purposes should be non-student specific, with no personally identifiable
information, this information does not need to be stored in a student’s record.
Health Room Visit Documentation
“A global transmittal of students’ health issues that contains identifiable, personal information
is not permissible under privacy laws and does not constitute best practice” (The Network for
Public Law, 2019). The use of multi-student logs that list the names of students with other
information is not recommended due to compromised confidentiality and lack of ability to
individually retrieve records. All health room visits by students should be documented. In the
absence of an electronic documentation system, the school nurse should have a paper process in
place to record the nursing process, document sensitive health issues, and file episodic health
room visits as care is provided.
Electronic Health Records
The use of electronic health records (EHR) aligns with 21
st
Century Standards of School Nursing
Practice. Per the NASN Position Statement, this method of documentation provides school
nurses with the ability “to impact healthcare coordination, quality, safety, efficiency,
effectiveness, and equity” and is an essential tool for school nurses. NASN’s position statement
refers to software that is uniquely designed for the school nurse practice, includes the nursing
process, utilizes uniform nursing language and data, and complies with HIPAA and FERPA
privacy safety standards. As with all nursing documentation, EHR records should be entered in a
timely manner, be accurate, legible, complete, retrievable, and secured.
According to Bergren and Maughan, EHR documentation is the most efficient, effective, safe,
and secure method for managing health information of students (Bergren & Maughan, 2019).
Useful for school nurse organization, EHR documentation can assist with prioritization of
workflow, prevent errors, and measure trends and outcomes. “EHR data can serve as the
foundation for reports, program evaluation, quality improvement projects, evidence-based
decision making, best practices implementation, advocacy, policy development, grants, and
research” (Bergren & Maughan, 2019; Gutherie, 2019: NASN, 2020). Especially useful as a
data collection tool, documentation in an EHR can influence national, state, and local policy to
reflect school nursing standards of practice.
General Principles of Documentation
The following information can be found in School Nursing: A Comprehensive Text (Brous, E.,
2019, p. 149). NASN’s basic principles of documentation have been incorporated into state and