School, hospital and visiting nurses are now more often expected to record health information electronically, requiring shifts in procedure, skills and patient interaction.
The transition is cause for excitement and caution, NYSUT health care professionals say. Electronic reporting improves accountability and legibility, streamlines storage and provides support for clinical decisions. It can also help track trends.
Last year, for example, the state Department of Health set up a reporting system during the outbreak of the H1N1 virus, as public health law requires reporting of communicable diseases.
"At first it was a little daunting, but it was so valuable identifying trends and predicting symptoms," said school nurse Joanne Reynolds, a member of the Scotia-Glenville Professional Registered Nurses Association.
Data collected also demonstrates the many services school nurses provide. But electronic reporting can lessen contact time with patients.
"NYSUT wants to make sure its health care members protect their work and their patients. They need to make sure their employers, especially school districts, have record-keeping policies," said Kathleen Donahue, NYSUT vice president whose office oversees health care professionals.
All nurses must adhere to the Health Insurance Portability and Accountability Act (HIPAA). School nurses also must follow the Family Educational Rights and Privacy Act (FERPA). A local district's policy can be more restrictive than state policy, but not less.
Policies are required for proper maintenance, accessibility, retention, record elimination and confidentiality, said Reynolds. "Your documentation is so linked to your licensure.
You absolutely need to determine before you start documenting: What are the security provisions? Who is allowed to view?" Electronic records kept by nurses are password-protected and not part of a global health care record, she said. Accounts or passwords should never be shared. "I would always refrain from putting personally identifiable information in an email," Reynolds said.
Districts also need to provide records storage that is protected from physical and environmental damage. (Consider the schools lost in New York after flooding this fall.)
While Utica Visiting Nurses Association member Julia Elacqua agrees information is more organized and accessible with electronic reporting, she said nurses need to be sure they do not put more energy into data entry than direct patient contact and documenting.