School Nurse Documentation: Complete FERPA-Compliant Guide
Master school nurse documentation with this comprehensive guide. Learn ADPIE and SOAPIE formats, IHP templates, medication administration logs, and emergency action plans. Includes FERPA compliance strategies, state requirements, and practical templates for K-12 school health offices.
School Nurse Documentation
In This Guide
What is School Health Documentation?
School health documentation is the comprehensive record-keeping system used by school nurses to track student health information, health office visits, screenings, medications, chronic health conditions, and emergency care. Unlike hospital or clinic documentation, school nurse charting operates under FERPA (Family Educational Rights and Privacy Act) rather than HIPAA, making it part of the student's education record.
School nurses document to ensure safe, effective care; communicate with parents, providers, and school staff; meet regulatory requirements; protect students and themselves legally; and support students' ability to attend school and access education despite health challenges.
Daily Documentation
- Health office visit logs
- Medication administration
- First aid and injuries
- Parent contacts
- Quick SOAP notes
Comprehensive Plans
- Individualized Health Plans (IHP)
- Emergency Action Plans (EAP)
- 504 health accommodations
- Chronic disease management
- Care coordination
Compliance Records
- Immunization tracking
- State-mandated screenings
- Health assessments
- Communicable disease reporting
- Staff training logs
Key Difference: FERPA, Not HIPAA
Most K-12 schools are NOT HIPAA-covered entities. Student health records maintained by school nurses are education records under FERPA. This means different privacy rules, parent rights, and consent requirements compared to traditional healthcare settings. Understanding FERPA is essential for school nurse documentation compliance.
School Nurse Documentation Formats
School nurses use nursing process-based formats that work well for the variety of situations encountered in health offices - from minor injuries to complex chronic conditions.
ADPIE
Assessment, Diagnosis, Planning, Implementation, Evaluation
The nursing process applied to school health encounters - ideal for health office visits and screening documentation
Best for: Daily health office visits, acute illness/injury assessments, health screening documentation
Assessment
Student complaint, objective findings, vital signs if indicated
Diagnosis
Nursing judgment about the health issue or concern
Planning
Plan of care including interventions, referrals, notifications
Implementation
Actions taken - first aid, medications, comfort measures, contacts made
Evaluation
Student response, disposition (return to class, sent home, 911)
Date: 01/15/2025 Time: 10:30 AM Student: Sarah M., Grade 4, Ms. Johnson's class Reason for visit: Stomach pain ASSESSMENT S: Student reports "my stomach hurts really bad" and rates pain 7/10. States pain started after breakfast, located in epigastric area. Denies nausea, vomiting, diarrhea, fever. Last bowel movement yesterday morning. Ate breakfast at school (pancakes, milk). No known food allergies. No significant medical history per health record. O: Student appears uncomfortable, holding abdomen. Alert and oriented. Abdomen soft, mild tenderness to palpation in epigastric area, bowel sounds present x4 quadrants. No guarding or rebound. Skin warm and dry, normal color. Temp: 98.4°F (tympanic). HR: 88. No signs of acute distress. DIAGNOSIS Abdominal pain of unclear etiology. Possible gastritis vs. anxiety (student mentioned math test today). No signs of acute abdomen requiring immediate medical attention. PLANNING - Rest in health office for 15-20 minutes - Apply heating pad to abdomen - Small amount of crackers and water if tolerated - Contact parent to inform and assess need for pickup - Monitor for worsening symptoms - Return to class if improved; parent pickup if not improved IMPLEMENTATION - Student rested on cot with heating pad to abdomen x 20 minutes - Offered 4 saltine crackers and 4oz water - tolerated without difficulty - Called mother at 10:35 AM - informed of situation. Mother reports no similar symptoms at home, agrees with plan to monitor and will be available for pickup if needed - Reassessed student at 10:50 AM EVALUATION Student reports pain decreased to 3/10. Appears more comfortable, smiling. States "I feel better now." Agrees to return to class with permission to return to health office if pain returns. Returned to class at 10:55 AM with pass. Teacher notified to monitor and send student back if symptoms worsen. Mother will follow up at home this evening.
SOAPIE
Subjective, Objective, Assessment, Plan, Intervention, Evaluation
Extended SOAP format used for comprehensive health assessments and complex student health situations
Best for: IHP assessments, comprehensive health evaluations, complex or chronic health conditions
Subjective
Student/parent-reported symptoms, concerns, history
Objective
Measurable findings: vitals, observations, screening results
Assessment
Clinical judgment and nursing diagnosis
Plan
Care plan including interventions, accommodations, follow-up
Intervention
Specific actions taken and services provided
Evaluation
Effectiveness of plan and student outcomes
INDIVIDUALIZED HEALTH PLAN ASSESSMENT Student: Marcus T., Grade 7, Age 12 Date: 09/05/2024 Condition: Type 1 Diabetes Mellitus SUBJECTIVE Parent reports Marcus was diagnosed with Type 1 Diabetes in June 2024. Currently on insulin pump therapy (Omnipod). Parent states "He's still learning to manage his numbers and the pump." Marcus reports checking blood glucose 6-8 times daily. Experiences occasional low blood sugar symptoms during PE class. States he knows signs of low blood sugar: "shaky, sweaty, dizzy." Denies any episodes requiring glucagon. Parent concerned about management during school day and field trips. OBJECTIVE Alert, cooperative 12-year-old male. Omnipod insulin pump in place on right upper arm, site clean and intact. Glucometer and supplies present in diabetes kit. Student demonstrated proper blood glucose check: 142 mg/dL at 11:00 AM. Correctly identified location of fast-acting carbs (glucose tabs, juice boxes) in diabetes kit. Able to verbalize symptoms of hypoglycemia and hyperglycemia. Demonstrated carb counting for lunch items. Reviewed emergency glucagon kit - expiration date 03/2025. Health History Review: - Diagnosed Type 1 Diabetes: June 2024 - Insulin pump: Omnipod (changed every 3 days) - Target blood glucose: 80-150 mg/dL - HbA1c: 7.2% (last checked 08/2024) - Endocrinologist: Dr. Patel, Pediatric Diabetes Center - No other chronic conditions - Allergies: NKDA ASSESSMENT Student with newly diagnosed Type 1 Diabetes requiring comprehensive school-based diabetes management plan. Student demonstrates good understanding of diabetes self-management for age but needs nursing support during school day. Risk for hypoglycemia during increased physical activity. Need for staff education and emergency protocols. PLAN 1. Individualized Health Plan (IHP) developed with parent, student, endocrinologist input 2. 504 Plan established for diabetes-related accommodations 3. Staff training on diabetes basics, signs/symptoms of hypo/hyperglycemia, emergency procedures 4. Unlimited access to water, bathroom, health office 5. Permission to check blood glucose, administer insulin, treat lows in classroom 6. Scheduled check-in before PE class 7. Snack access as needed for blood glucose management 8. Field trip planning protocol 9. Emergency action plan with glucagon administration protocol 10. Quarterly IHP review meetings with parent/student IMPLEMENTATION - IHP completed and signed by parent, school nurse, physician (09/05/2024) - 504 Plan meeting scheduled for 09/12/2024 - Diabetes kit stored in health office with backup supplies - Classroom kit prepared for Marcus to carry (glucometer, lancets, test strips, glucose tabs, fast-acting carbs) - Teacher and PE teacher trained on diabetes basics and emergency procedures (09/06/2024) - Two staff members trained on glucagon administration (Principal Jones, Secretary Martinez) - Emergency glucagon kit stored in health office (labeled, expiration tracked) - Emergency action plan posted in health office and provided to relevant staff - Parent contact information updated; mother's cell is primary emergency contact - Endocrinologist orders on file for insulin pump parameters and blood glucose management EVALUATION Student demonstrates competence in diabetes self-management appropriate for age. Parent engaged and supportive. IHP implementation successful. Student checking blood glucose before lunch and PE without reminders. No hypoglycemic episodes requiring intervention in first month. Student reports feeling supported and "not singled out." Plan to continue with quarterly reviews and adjust as needed based on student's developmental stage and diabetes management. Next review scheduled for 12/05/2024.
SOAP (Brief)
Subjective, Objective, Assessment, Plan
Streamlined format for routine health office visits and straightforward encounters
Best for: Minor injuries, simple illnesses, routine medication administration, brief health office visits
Subjective
Chief complaint in student's/parent's words
Objective
Observable findings and assessments
Assessment
Nursing judgment
Plan
Disposition and follow-up
Date: 02/20/2025 Time: 1:45 PM Student: Jake R., Grade 10 Visit: Headache S: Student reports headache x 1 hour, pain level 5/10, frontal area. Denies visual changes, nausea, head injury. States he "forgot to eat lunch" and "has a big test next period." Takes no regular medications. No allergies. O: Alert and oriented. Pupils equal, round, reactive to light. No apparent distress. Denies photophobia. Lungs clear. Temp 98.2°F. A: Tension headache, likely related to hunger and test anxiety. P: Encouraged student to eat snack from health office (granola bar, water). Rest x 10 minutes. Deep breathing exercises reviewed for test anxiety. Student reports headache improved to 2/10. Returned to class at 2:00 PM with pass. Encouraged to eat regular meals and use stress management techniques.
Types of School Health Records
School nurses maintain various types of health records, each with specific purposes, requirements, and retention periods.
Immunization Records
Track state-required immunizations for school entry and compliance
Required Elements:
- State-required vaccines per grade level
- Dates of each dose
- Vaccine lot numbers and manufacturer
- Healthcare provider signature/stamp
- Religious or medical exemptions (if applicable)
- Certificate of Immunization Status (CIS)
- Exemption documentation per state law
- Annual audit compliance verification
Retention:
Varies by state - typically until 1-2 years after graduation or until age of majority
FERPA Note:
Immunization records are education records under FERPA and require written consent for disclosure (except in emergencies or to comply with public health requirements).
Health Screenings
Document mandated and routine health screenings for early detection of health issues
Required Elements:
- Vision screening results (by grade per state mandate)
- Hearing screening results (by grade per state mandate)
- Height, weight, BMI calculations and percentiles
- Scoliosis screening (typically grades 5-9)
- Dental screening (if mandated)
- Screening date and personnel
- Referral forms for failed screenings
- Parent notification of results
- Follow-up documentation
Retention:
Until student graduates or transfers; aggregate data retained per state requirements
FERPA Note:
Screening results are protected under FERPA. Parent notification required. Cannot share results with teachers without consent unless relevant to IHP/504.
Medication Administration Logs (MAR)
Document all medications administered during school day
Required Elements:
- Student name and grade
- Medication name, dose, route, time
- Prescriber name and signature/stamp on order
- Parent written permission
- Date medication started
- Indication/reason for medication
- Student response/effectiveness
- Adverse reactions
- Witness signature (if required by policy)
- PRN documentation including reason given and response
- Missed dose documentation with reason
Retention:
Typically 3-7 years per state nursing practice act and district policy
FERPA Note:
Medication logs are FERPA-protected. Cannot share with school staff without parent consent unless part of approved IHP/504 plan.
Emergency Care Plans
Document life-threatening conditions and emergency response protocols
Required Elements:
- Diagnosis and triggers
- Signs/symptoms of emergency
- Step-by-step emergency protocol
- Medication administration instructions (EpiPen, rescue inhaler, glucagon, diastat)
- When to call 911
- Parent emergency contact information
- Physician orders and signature
- Parent signature acknowledging plan
- Staff training documentation
- Annual review and update
Retention:
Current year plus 3-7 years after graduation/withdrawal
FERPA Note:
Can share emergency plans with staff who have legitimate educational interest (teachers, administrators). Vital for student safety.
Individualized Health Plans (IHP)
Comprehensive plan for students with chronic health conditions
Required Elements:
- Health condition diagnosis and history
- Nursing assessment findings
- Student/parent input and concerns
- Nursing diagnoses
- Measurable goals and objectives
- Interventions and nursing care
- Medications and treatments
- Accommodations needed
- Emergency protocols
- Evaluation of plan effectiveness
- Signatures (parent, nurse, physician)
- Review dates and updates
Retention:
Duration of enrollment plus 3-7 years
FERPA Note:
IHPs are FERPA-protected. Share relevant portions with school team on need-to-know basis with parent consent (or as part of 504/IEP).
Health Office Visit Logs
Document all student visits to health office
Required Elements:
- Date and time of visit
- Student name, grade, teacher
- Chief complaint/reason for visit
- Vital signs if indicated
- Assessment findings
- Nursing interventions provided
- Disposition (return to class, parent pickup, 911)
- Parent contact and response
- Follow-up needed
- Time student left health office
Retention:
Current year plus 3-5 years per district policy
FERPA Note:
Visit logs are education records. Aggregate data (e.g., frequent flyers) may inform student support plans but individual visit details require consent to share.
FERPA vs HIPAA in School Settings
Understanding the difference between FERPA and HIPAA is critical for school nurses. Most K-12 schools operate under FERPA, not HIPAA, which affects how you document, share, and protect student health information.
| Aspect | FERPA (School Nurses) | HIPAA (Healthcare) |
|---|---|---|
| Which Law Applies? | Applies to all K-12 schools receiving federal funding | Generally does NOT apply to school health offices (schools are not "covered entities") |
| What is Protected? | Education records including all health and medical records maintained by school | Protected Health Information (PHI) at covered healthcare providers |
| Parent Rights | Parents have right to inspect, review, and request amendments to education records | Patients (or personal representatives) can access medical records |
| Consent for Disclosure | Requires written parent consent except for "legitimate educational interest," emergencies, or directory info | Written authorization required with specific elements |
| Emergency Exceptions | Can disclose without consent in health/safety emergency | Can disclose to prevent/lessen serious threat to health or safety |
| School Staff Access | Staff with "legitimate educational interest" can access records without consent | Access limited to minimum necessary for treatment, payment, operations |
What School Nurses Need to Do:
Which Law Applies?: Follow FERPA for all student health records. HIPAA applies only if school operates a separate clinic billing insurance.
What is Protected?: Treat all student health information as FERPA-protected education records.
Parent Rights: Provide parents access to student health records within 45 days of request. Explain content, provide copies.
Consent for Disclosure: Get written parent consent before sharing health info with teachers, coaches, etc. Document "need to know" for each disclosure.
Emergency Exceptions: In emergency (e.g., 911 call, imminent threat), can share necessary health info without consent. Document emergency justification.
School Staff Access: Share health info with teachers/staff only if they need it to provide educational services/ensure safety (IHP, 504, emergency plans).
Exception: School-Based Health Centers
If your school operates a separate school-based health center (SBHC) that bills Medicaid/insurance for services, that clinic IS a HIPAA-covered entity and must follow HIPAA rules. Regular school health office records remain under FERPA. Keep these records separate if both exist at your school.
Documentation by School Level
Elementary, middle, and high school health offices have different priorities and documentation needs based on student developmental stages.
Elementary School (K-5)
Primary Focus: Injury care, illness assessment, parent communication, medication administration
Common Visits:
- Minor injuries (playground falls, scrapes)
- Stomach aches and headaches
- Separation anxiety (especially K-1)
- Fever/illness assessment
- Lice checks
- Asthma/allergy management
Documentation Tips:
- Use age-appropriate language when documenting student statements
- More parent contact - elementary parents expect calls for minor issues
- Document student affect and behavior (crying, wanting parent, etc.)
- Note if student frequently visits at same time daily (may indicate anxiety, avoidance)
- Ice pack and band-aid documentation can be simplified but should be logged
Middle School (6-8)
Primary Focus: Puberty-related issues, mental health, sports injuries, peer conflicts
Common Visits:
- Menstrual issues (cramps, first period, supplies)
- Anxiety and peer relationship stress
- Sports-related injuries
- Headaches (often stress-related)
- Somatic complaints
- Acne and skin concerns
Documentation Tips:
- Respect student privacy - ask if they want to discuss concerns privately
- Document mental health concerns carefully (anxiety, depression, self-harm)
- May need to document parent refusal to pick up student
- Frequent flyers - document patterns, discuss with counselor/team
- Document developmental/puberty education provided
High School (9-12)
Primary Focus: Independence, sports medicine, mental health, chronic disease management
Common Visits:
- Sports injuries (concussion protocol!)
- Mental health issues (anxiety, depression, panic attacks)
- Medication administration (ADHD meds, mental health meds)
- Chronic disease self-management support
- Reproductive health questions
- Fatigue and stress
Documentation Tips:
- Students may resist parent contact - document when student refuses
- Concussion documentation must be thorough (return-to-play protocols)
- Mental health documentation - be specific but sensitive
- Support adolescent independence while maintaining safety
- Document if student leaves health office without permission
- College-bound students - provide immunization records, health summaries
IEP and 504 Plan Documentation
School nurses play a crucial role in IEP and 504 Plans when health conditions impact a student's ability to access education. Understanding your documentation responsibilities for each is essential.
504 Plan
School Nurse Role: Provide health-related information and accommodations
Documentation Requirements:
- Nursing assessment documenting impact of health condition on learning
- Medical documentation (physician orders, diagnosis)
- Specific accommodations needed (bathroom access, rest periods, medication)
- Emergency protocols if applicable
- Attendance at 504 meetings (document participation)
- Progress monitoring of health accommodations
- Annual review participation and updates
Common Health Conditions Requiring 504 Plan:
IEP (Individualized Education Program)
School Nurse Role: Provide health services if needed for student to benefit from special education
Documentation Requirements:
- Health services determination (is nursing service needed for student to access education?)
- IHP if health services are part of IEP
- Nursing goals and objectives if applicable
- Medication administration
- Specialized health procedures (tube feeding, catheterization, suctioning)
- Documentation of health services provided
- IEP meeting participation notes
- Coordination with special education team
Common Health Conditions Requiring IEP (Individualized Education Program):
Key Difference Summary
504 Plan:
Accommodations for students with disabilities to access general education. Health conditions qualify if they substantially limit a major life activity (learning, breathing, caring for oneself). Most school health plans are 504 Plans.
IEP:
Special education services for students who need specialized instruction. Health services included in IEP only if necessary for student to benefit from special education (e.g., complex medical needs requiring nursing care during school day).
Medication Administration Documentation
Medication administration is a high-risk activity requiring meticulous documentation. Three forms are required, and every dose must be logged.
Physician Order/Authorization
Annually or with any medication changeMust Include:
- Student name and date of birth
- Medication name (generic and brand)
- Dose, route, frequency
- Time(s) to be administered
- Diagnosis/reason for medication
- Possible side effects
- Prescriber signature and date
- Prescriber contact information
- Start and end dates (if applicable)
Parent/Guardian Authorization
AnnuallyMust Include:
- Parent signature permitting medication administration at school
- Parent emergency contact information
- Acknowledgment of responsibility to provide medication
- Permission for nurse to discuss medication with prescriber if needed
- Release of liability (depending on district policy)
- Date signed
Medication Log (MAR)
3-7 years per state requirementsMust Include:
- Each date medication given
- Actual time administered
- Nurse signature or initials
- For PRN: reason given, response/effectiveness
- Missed doses with reason
- Medication errors with follow-up
- Discontinuation date
PRN (As Needed) Medication Documentation
Must document reason medication given (e.g., headache, pain level, asthma symptoms)
Must document student response/effectiveness within appropriate timeframe
Must follow prescriber parameters (e.g., "may give for headache rated 5/10 or higher")
Document why PRN NOT given if student requests but doesn't meet criteria
Track frequency - alert parents/prescriber if PRN use increasing
Date: 03/15/2025 Time: 11:30 AM Student: Emma S., Grade 8 Medication: Ibuprofen 400mg PO Reason: Student reports headache, pain level 6/10, frontal area. Last ibuprofen dose 03/14/2025 at 2:00 PM (>8 hours ago). No contraindications. Given: Ibuprofen 400mg PO at 11:35 AM with water. Student tolerated without difficulty. Response: Reassessed at 12:15 PM - student reports headache improved to 2/10. Returned to class at 12:20 PM. Nurse signature: J. Williams, RN
The Three Medication Documentation Rules
- Get it in writing (physician order, parent permission)
- Document every single dose (no exceptions, no shortcuts)
- When in doubt, don't give it - call parent/prescriber and document the call
Emergency Action Plans (EAPs)
Emergency Action Plans are life-saving protocols for students with conditions that can rapidly become life-threatening. Documentation must be detailed, current, and accessible to trained staff.
Severe Allergies (Anaphylaxis)
Triggers: Food allergies, insect stings, medications
Emergency Signs & Symptoms
- !Difficulty breathing, wheezing
- !Swelling of face, lips, tongue
- !Hives, widespread rash
- !Vomiting, diarrhea
- !Dizziness, loss of consciousness
- !Feeling of impending doom
Emergency Protocol
- 1Administer epinephrine auto-injector immediately to outer thigh
- 2Call 911 - state "anaphylaxis" and give location
- 3Call parent/emergency contact
- 4Keep student lying down (or sitting if breathing easier)
- 5Second dose of epinephrine in 5-15 minutes if no improvement
- 6Monitor vital signs until EMS arrives
- 7Send EpiPen with student to hospital
Documentation Requirements:
Document exact time of symptom onset, epinephrine given, 911 call, parent notification. Note student response. Detailed narrative format required.
Asthma Attack
Triggers: Exercise, allergens, respiratory infections, stress
Emergency Signs & Symptoms
- !Severe shortness of breath
- !Inability to speak in full sentences
- !Retractions (chest sinking in)
- !Peak flow <50% of personal best
- !Blue lips or fingernails
- !Decreased level of consciousness
Emergency Protocol
- 1Administer rescue inhaler per student's emergency plan (usually 2-6 puffs with spacer)
- 2Keep student calm, sitting upright
- 3Assess response in 5-10 minutes
- 4Call 911 if: no improvement, severe distress, unable to speak, lips/nails blue
- 5Call parent
- 6Continue rescue inhaler every 5-10 minutes until EMS arrives if needed
- 7Do NOT leave student alone
Documentation Requirements:
Document respiratory assessment, peak flow if obtained, rescue inhaler given (puffs, time), student response, disposition. For 911 calls, detailed timeline required.
Seizure
Triggers: Epilepsy, head injury, fever, medication changes
Emergency Signs & Symptoms
- !Seizure lasting >5 minutes
- !Repeated seizures without regaining consciousness
- !Difficulty breathing after seizure
- !Injury during seizure
- !First-time seizure
- !Seizure in water
Emergency Protocol
- 1Protect student from injury - cushion head, clear area
- 2Time the seizure (start to stop)
- 3Turn student on side if possible (recovery position)
- 4Do NOT restrain or put anything in mouth
- 5If seizure >5 minutes: administer emergency medication (diastat, nasal midazolam) per order and call 911
- 6Call parent
- 7After seizure: keep student on side, allow to rest, monitor breathing and level of consciousness
- 8Document post-ictal period
Documentation Requirements:
Document seizure duration, type (if known), emergency medication given, 911 call if applicable, post-seizure status. Parent notification. Very detailed narrative required.
Diabetes Emergency
Triggers: Hypoglycemia (low blood sugar) or Hyperglycemia (high blood sugar)
Emergency Signs & Symptoms
- !HYPOGLYCEMIA (<70 mg/dL): shaking, sweating, confusion, loss of consciousness
- !HYPERGLYCEMIA (>250 mg/dL with ketones): nausea, vomiting, abdominal pain, fruity breath, altered mental status
Emergency Protocol
- 1HYPOGLYCEMIA: If conscious - give fast-acting carbs (juice, glucose tabs). Recheck in 15 min. If unconscious - glucagon injection and call 911
- 2HYPERGLYCEMIA: Check ketones if able, encourage water, contact parent for insulin guidance. Call 911 if altered mental status or severe symptoms
- 3Never leave student alone
- 4Document blood glucose readings
Documentation Requirements:
Document blood glucose level, symptoms, treatment given (glucose tabs, juice amount, glucagon), response, repeat blood glucose, parent contact, 911 if called. Timeline critical for hypoglycemia.
EAP Documentation Checklist
Electronic Health Record Systems for Schools
Many school districts are transitioning from paper to electronic health records. These systems help streamline documentation, improve compliance, and save time.
Magnus Health
Key Features:
- Health records management
- Immunization tracking
- Medication administration
- Screening documentation
- Parent portal
- Compliance reporting
Best for: Comprehensive K-12 health office management
Snap Health Center
Key Features:
- EHR for school nurses
- Visit documentation
- IHP management
- State screening compliance
- Medication tracking
- Secure messaging
Best for: Districts needing full EHR functionality
SchoolCare Works
Key Features:
- Electronic health records
- FERPA compliance
- Emergency action plans
- Visit tracking
- Reporting and analytics
- Mobile access
Best for: Medium to large school districts
Mednition
Key Features:
- Visit logs
- Medication management
- IHP templates
- Health screenings
- Parent notifications
- Data analytics
Best for: Growing districts transitioning from paper
PatientNotes (for School Nurses)
Key Features:
- AI-assisted documentation
- FERPA-compliant templates
- Quick visit notes
- IHP generation
- Voice-to-text documentation
- Customizable templates
Best for: School nurses wanting to reduce documentation time while maintaining compliance
Benefits of Electronic Health Records for School Nurses
Time Savings
Reduce documentation time by 30-50% with templates and auto-population
Improved Accuracy
Fewer errors with required fields, alerts, and medication checks
Better Compliance
Automatic reminders for screenings, immunizations, IHP reviews
Enhanced Communication
Secure messaging with parents, staff notifications
Data Analytics
Track trends, identify frequent flyers, generate reports
Accessibility
Access records from any school building, work from multiple locations
Common Documentation Mistakes to Avoid
These frequent errors can lead to FERPA violations, parent complaints, legal liability, and compromised student safety.
Sharing student health information without parent consent
Avoid:
Telling a teacher "Johnny has ADHD" or emailing health details to staff without consent.
Better:
Get written parent consent before sharing health information. Only share what is necessary for staff to know (e.g., IHP accommodations, emergency plans).
Why it matters: FERPA violation. Student health records are protected education records. Can result in complaints, lawsuits, and loss of parent trust.
Not documenting parent contact attempts
Avoid:
Calling parent multiple times but not documenting the attempts or responses.
Better:
Document every parent contact attempt: date, time, method (call, email, text), who you spoke with, message left or conversation summary.
Why it matters: Protects you if parent claims they were never contacted. Shows due diligence in parent communication.
Using student names in emails
Avoid:
Emailing "Can you send Susie Smith to the health office at 10 AM for her medication?"
Better:
Use initials or ID numbers in emails. Better yet, use secure messaging system. Never include diagnosis or medication names in unsecured email.
Why it matters: Email is not secure. FERPA requires protection of student privacy. Email can be forwarded or accessed by unauthorized individuals.
Incomplete medication administration logs
Avoid:
Initialing that medication was given but not documenting response, or skipping documentation when dose is missed.
Better:
Complete all fields: date, exact time given, nurse signature. For PRN: reason given and response. For missed doses: document reason and any action taken.
Why it matters: Medication logs are legal documents. Incomplete logs can't prove medication was given. Critical for defending against allegations or errors.
Not updating emergency action plans annually
Avoid:
Using the same EpiPen orders and emergency plan from 2 years ago.
Better:
Obtain new physician orders and parent signatures annually, or whenever condition changes. Verify emergency contacts and medication expiration dates at start of each school year.
Why it matters: Medical conditions change. Expired orders are not valid. Using outdated emergency plans can result in harm to student and liability.
Vague documentation of head injuries
Avoid:
Student hit head, seems fine, returned to class.
Better:
Detailed documentation: mechanism of injury, loss of consciousness (if any), symptoms (headache, nausea, dizziness), neurological assessment (pupils, orientation), instructions given to student/parent, concussion signs/symptoms handout provided.
Why it matters: Head injuries can have delayed symptoms. Vague documentation provides no protection if student later diagnosed with concussion. Concussion protocols and return-to-play require detailed documentation.
Not documenting when calling 911
Avoid:
Brief note "Called 911 for seizure" without details.
Better:
Detailed narrative with timeline: exact time of emergency, symptoms/situation, time 911 called, what was told to dispatcher, time EMS arrived, interventions performed before/during EMS care, student disposition, parent notification.
Why it matters: 911 calls indicate serious medical emergency. Detailed documentation protects you legally and provides critical information for continuity of care and future reference.
Allowing students to keep medications without proper authorization
Avoid:
Student says "my mom said I can keep my inhaler in my backpack."
Better:
Require physician order and parent written permission for student to self-carry ANY medication (including inhalers, EpiPens). Document self-carry authorization in student's health record. Some states require specific self-carry forms.
Why it matters: Legal requirement in most states. Protects school from liability. Ensures student is capable of self-administering safely. Without proper authorization, medication must be kept in health office.
State-Specific Requirements Overview
School nurse documentation requirements vary significantly by state. You must be familiar with your state's regulations for immunizations, screenings, medication administration, and delegation.
General Overview
State requirements vary significantly. School nurses must be familiar with their state's:
- Nurse Practice Act (defines scope of practice for school nurses)
- State Board of Nursing regulations
- State Department of Education health requirements
- Mandatory immunizations by grade
- Required health screenings (vision, hearing, scoliosis, dental)
- Medication administration regulations
- Delegation rules (can LPN or unlicensed staff give medications?)
- Concussion management laws
- Epinephrine and naloxone stocking requirements
- Health record retention requirements
- Reporting requirements (child abuse, communicable diseases)
Common Variations
Examples of how requirements differ by state:
- IMMUNIZATIONS: Some states allow religious exemptions, some do not. Some require Tdap booster in middle school, others don't.
- SCREENINGS: Vision/hearing screening grades vary. Some states mandate BMI screening and reporting, others prohibit it.
- MEDICATION: Some states allow trained unlicensed personnel to give medications, some require RN only. Epinephrine and glucagon rules vary.
- STANDING ORDERS: Some states allow standing orders for OTC medications, some require individual prescriptions.
- DELEGATION: Rules about what can be delegated to LPN or health aide vary widely.
- EPIPEN STOCKING: Many states now require schools to stock emergency epinephrine - check your state law.
- NALOXONE: Growing number of states require or allow schools to stock naloxone (Narcan) for opioid overdose.
Finding Your State's Requirements
State Board of Nursing: Defines RN scope of practice, delegation rules
State Department of Education: School health requirements, screenings, immunizations
State Department of Health: Immunization schedules, communicable disease reporting
National Association of School Nurses (NASN): State affiliate contacts and resources
Contact your state NASN chapter for a comprehensive guide to your state's school health documentation requirements.
Individualized Health Plan Template
Use this template to create comprehensive IHPs for students with chronic health conditions.
INDIVIDUALIZED HEALTH PLAN (IHP) STUDENT INFORMATION -------------------- Student Name: _______________________ DOB: __________ Grade: ______ School: ____________________________ Teacher: _____________________ Parent/Guardian: ___________________ Phone: ________________________ Emergency Contact: _________________ Phone: ________________________ Primary Care Provider: _____________ Phone: ________________________ Specialist: ________________________ Phone: ________________________ HEALTH CONDITION ---------------- Diagnosis: _________________________________________________________ Date of Diagnosis: _________________________________________________ Current Status: ____________________________________________________ STUDENT/PARENT INPUT -------------------- Student's understanding of condition: Parent concerns/priorities: Student's goals for managing health at school: NURSING ASSESSMENT ------------------ Current medications: Treatments/procedures required: Symptoms/triggers to monitor: Impact on school attendance/participation: Emergency protocols needed: ☐ Yes ☐ No NURSING DIAGNOSES ----------------- 1. 2. 3. GOALS AND INTERVENTIONS ----------------------- Goal #1: [Measurable goal] Interventions: - - Evaluation criteria: Goal #2: [Measurable goal] Interventions: - - Evaluation criteria: Goal #3: [Measurable goal] Interventions: - - Evaluation criteria: ACCOMMODATIONS NEEDED --------------------- ☐ Medication administration during school day ☐ Bathroom/water access without permission ☐ Rest periods in health office ☐ Snack access ☐ PE/recess modifications ☐ Testing accommodations ☐ Late arrival/early dismissal ☐ Attendance flexibility ☐ Other: __________________________________________________________ EMERGENCY PROTOCOL ------------------ Signs/symptoms requiring immediate intervention: Emergency medications: When to call 911: Parent notification procedures: CARE COORDINATION ----------------- Staff requiring training: __________________________________________ 504 Plan needed: ☐ Yes ☐ No If yes, meeting date: __________ IEP involvement: ☐ Yes ☐ No EVALUATION AND REVIEW --------------------- Plan effective date: _______________ Next review date: _________________ (Minimum annually) Progress monitoring method: SIGNATURES ---------- School Nurse: _________________________ RN Date: ______________ Parent/Guardian: ______________________ Date: ______________ Physician/Provider: ___________________ Date: ______________ Principal/Designee: ___________________ Date: ______________ Student (if appropriate): _____________ Date: ______________
Create IHPs Faster with AI
PatientNotes helps school nurses generate comprehensive, individualized health plans in minutes instead of hours. Input student information and health details, and get a complete, FERPA-compliant IHP ready for review.
Try PatientNotes FreeFrequently Asked Questions
Does HIPAA or FERPA apply to school nurse documentation?
FERPA (Family Educational Rights and Privacy Act) applies to school nurse documentation, not HIPAA. Schools are generally not HIPAA-covered entities. All student health records maintained by the school are considered education records under FERPA and require written parent consent for disclosure, except for legitimate educational interest, emergencies, or directory information.
What format should school nurses use for documentation?
School nurses commonly use ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation) for health office visits, SOAPIE for comprehensive health assessments and IHPs, and brief SOAP format for routine visits. The format should match the situation - detailed for complex issues, streamlined for minor injuries.
What is an Individualized Health Plan (IHP)?
An IHP is a comprehensive care plan for students with chronic health conditions (diabetes, asthma, seizures, severe allergies). It includes nursing assessment, nursing diagnoses, goals, interventions, emergency protocols, and accommodations needed for the student to safely access education. IHPs are developed with parent, student, and physician input and reviewed regularly.
How long must school health records be kept?
Retention requirements vary by state and record type. Generally, student health records should be kept for the duration of enrollment plus 3-7 years. Immunization records may need to be kept until 1-2 years after graduation or until age of majority. Medication administration records are typically kept 3-7 years. Check your state Department of Education and Board of Nursing regulations.
Can school nurses share student health information with teachers?
School nurses can share student health information with teachers who have a "legitimate educational interest" under FERPA - meaning they need the information to provide educational services or ensure student safety. This includes IHP accommodations, emergency action plans, and relevant health information. Document what was shared, with whom, and why. Best practice is to obtain written parent consent even when FERPA allows disclosure.
What documentation is required for medication administration at school?
Three documents are required: 1) Physician order/authorization with medication name, dose, route, time, and prescriber signature, 2) Parent written permission for medication administration at school, and 3) Medication Administration Log (MAR) documenting each dose given, time, nurse signature, and for PRN medications, the reason given and student response. All three must be current (renewed annually or with changes).
When should a school nurse call 911?
Call 911 for: severe allergic reaction/anaphylaxis, severe asthma attack not responding to treatment, seizure lasting >5 minutes, head injury with loss of consciousness, suspected fracture or serious injury, chest pain or difficulty breathing, severe bleeding, altered mental status, diabetic emergency with loss of consciousness, any situation where student needs emergency medical care beyond school nurse scope. Always document 911 calls with detailed timeline and follow up with parents.
What is the difference between a 504 Plan and an IEP for health conditions?
504 Plans provide accommodations for students with disabilities (including health conditions) to access general education. IEPs are for students who need special education services. A student with diabetes might have a 504 Plan with accommodations (bathroom access, snacks, testing flexibility) but wouldn't need an IEP unless the diabetes impacted learning to the extent that special education was required. School nurses often provide health information for both, but IEPs require determination that health services are necessary for the student to benefit from special education.
Spend More Time with Students, Less on Paperwork
PatientNotes helps school nurses document faster with AI-powered templates for IHPs, visit logs, medication records, and emergency action plans. FERPA-compliant and designed for K-12 schools.
No credit card required. FERPA compliant. Built for school nurses.