Legal Issues 101: Documentation and School Records

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.

Keywords

documentation data collection quality improvement health records legal/ethical issues school health data HIPAA FERPA

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