Treatment notes and online student medical records
Charts. Notes. Treatments. Screenings. Logs. Reports. Visits. Whatever you call them (I prefer treatment notes) the documentation you make on student visits and treatment is important. Check that, very important.
Every time a student is treated at the health center, a record needs to be in place, not only for the sake of protecting the health care provider, and the school, but more importantly so that the student has a complete health history. With a full student health history, providers can look at the total picture of health, observe trends, accurately note when something occurred, when a shot was given, or simply note that the student is a frequent flier to the health center.
Doctors’ offices chart every patient visit. Why would a school health center be any different? They shouldn’t be. That’s why we created a versatile treatment note module within our online student medical record. To chart a student visit is easy. Search for a student, click add a note, fill in the blanks, and save. You can prefill treatment notes for commonly treated issues, and specify any fields you want, like medication, complaint, treatment, or additional comments. Every note contains the date, time, and duration of visit. And, schools can decide if they want to share the note with parents. The beauty here is that for a common cough or headache, maybe the nurse doesn’t see the need in alerting the parents. But if the student is a frequent flier, or if something more serious is going on, the nurse may want the parent to get an alert with those details. And believe us, parents will thank you for making the process easy for them, too.
Not only can you control if parents see the chart or not, using permissions, you can control which school employees are privy to that information as well. For example, the school nurse most likely has visibility over all treatment notes, and teachers have no visibility. Or, maybe the nurse and athletic trainer, and other specific employees can view them (because involving the whole school does matter). It’s truly set up to the needs of your school. You decide who, you decide when, you decide where, the information is accessed.
Did I mention this is all online? Allow me to say it. This is all online. You won’t have to try and decipher handwriting any longer. Every chart is online, typed, legible, and saved within the student medical record, so the nurse can look back at the student’s history, or show the history to parents or other health care providers.
Want to see what else this software for school nurses can do? Reserve a free demo today.