Legally Defensible Health Documentation

Proper documentation is one of the best ways you can protect yourself in the face of legal action. While it’s not particularly common for school nurses to face liability issues, the consequences if you do encounter a legal issue are serious. And because documentation is something you do all the time, it’s both an easy way to protect yourself and an easy way to get into trouble. In this post, we’ll provide best practices so that you can ensure your documentation meets the legal and professional standards for K-12. 

Why Legally Defensible Documentation Matters  

So what is legally defensible documentation? Simply put, it’s documentation that, if ever used in a legal proceeding, would show that the school nurse upheld the standard of care and followed all policies and procedures set by the government (whether local, state, or federal) and the district.  

Outside of legal proceedings, documentation could be scrutinized after an emergency to understand whether the situation could have been avoided and whether everyone involved followed the proper procedures. While this protects staff, it also helps schools ensure they are doing everything in their power to keep students safe.  

Key Elements of Legally Defensible Student Health Documentation  

While legally defensible documentation will depend on your school’s policies, there are some tips that generally contribute positively to your notes. If these seem like common sense, that’s a good thing! They shouldn’t feel like they’re coming out of left field. 

1. Accuracy 

Of course, notes should be precise and true. But the key differentiator here is objectivity. You want to record symptoms not in terms of your subjective perspective on them, but in terms of what you see in front of you. This aspect becomes especially important when you have other people who might need to access medical records and understand a child’s symptoms over time.  

2. Timeliness 

We’ve talked about contemporaneous documentation before, and it’s critical. With the number of students that many school nurses see in a day, documenting health incidents and actions in real time or as soon as possible is the best way to ensure that your documentation is as accurate as possible. Contemporaneous charting holds more weight in legal settings. And if you have an electronic health records system, you can show exactly when you documented a visit.  

3. Consistency 

Consistency of care is important in your health services program for so many reasons. Thinking about consistency in this context, we’re thinking about using standardized forms, templates, and protocols across your district. With so many students to care for, consistency and standardization are your best bets at making sure no one slips through the cracks.  

4. Compliance & Confidentiality 

It might feel like a given, but meeting FERPA and HIPAA standards is another key in legally defensible documentation. That might mean avoiding writing notes on post-its, ensuring your documentation system is compliant, and making sure your system is secure to keep student data safe. It might feel frustrating to have your work computer automatically lock throughout the day, but it’s a simple way to stay compliant with privacy laws.  

Common Pitfalls and How to Avoid Them  

You might be thinking that with the stakes so high, how could anyone ever not ensure all of their documentation is legally defensible? More often than not, documentation pitfalls fall into one of the following categories: training, language, verbal communication, and details. 

With inadequate training, staff may not be aware of all of the legal and ethical documentation standards. Regular staff training and consistent professional development is good idea to ensure everyone knows what’s needed. Subjective language is another pitfall. Documentation should always be fact-based, so staff should avoid interpretations of behaviors and instead record objective observations. Verbal communication might show up when you have a busy workload and it feels easier or faster to verbally communicate about a student rather than documenting everything. Become a “document everything” culture and you’ll end up in a better situation! Lastly, incomplete documentation is not legally defensible documentation.  

Technology’s Role in Improving Documentation Practices 

Many of the pitfalls of legally defensible documentation become infinitely easier with an electronic health records system. Depending on the system you choose, an EHR can require fields that you’d need for comprehensive documentation, and it can make documentation for group events much easier, so there’s less risk of missing notes when you’re working on group screenings.  

Frontline School Health Management was made exclusively for K-12 school nurses, and makes it easier for schools to stay compliant even with rising rates of students requiring support for mental health challenges and chronic illnesses.