fail to orient their health center staff to the camp’s expectations surrounding documentation. Just as one thinks through documentation guidelines for incidents that occur outside the health center so, too, should one consider what guides documentation done by health center staff. In general, documentation done by health center staff should (a) accurately reflect the client-provider interaction in a timely manner; (b) be appropriate to the healthcare provider’s scope of practice; (c) comply with legal and professional practice standards for healthcare documentation; and (d) serve to protect both the camp and the provider. The sidebar below contains a sample documentation policy for nurses who staff a camp health center. The professional staff working in the health center will know their profession’s documentation standards. What they need from their camp supervisor is a conversation about how that plays out in the camp setting. When and how the camp log is used should be explained. When and how to document care given to a camper or staff member needs explaining. How and where one records phone conversations with parents or external consultants (e.g., the camper’s MD, a 18 CAMPING magazine • March/April 2014 pharmacist, a mental health professional) should be discussed. The scope of computer-based record keeping needs explanation along with instruction that each health center staff member uses his or her own username/password to assure tracking (e.g., who entered what data when on that computer-based record). If not instructed, these same healthcare professionals may approach documentation with an “it’s just camp” attitude, and their documentation may not comply with the standard of practice for their profession. They have been known to provide too little information, which becomes especially problematic should an incident occur. For example, writing “headache; two Tylenol” on a client record does not describe assessment nor evaluation; consequently, it is not sufficient documentation for nurses. How much better to read: “Client headache related to sun glare from guarding without polarized sunglasses; provided 650 mg Tylenol with 8 oz water with instruction to use appropriate sunglasses and return in one hour if headache not improved.” Yes, it takes time to appropriately document. Allowance for this time must be acknowledged and provided by supervisors, even if that supervisor is not a healthcare professional. Making sure there’s adequate time to document can be tricky when the health center is particularly busy, such as the time just before bed or when an outbreak occurs. Supervisors can help health center staff identify strategies to address this challenge. Something as simple as making a brief note in a log and then returning to more thoroughly document on the client health record a bit later might be all it takes. Train Staff Because staff provide documentation, explain the camp policies surrounding appropriate documentation practices. This might include not discussing information with others unless the camp’s administration or attorney is present. It may include the policy of documenting within a specific timeframe to preserve memory, as well as a reminder that documentation may be read by people beyond the director. Be sure staff understand who receives their documentation and who they can consult should questions arise during the process of documenting. Also make clear just who “owns” the documentation. May a parent, for example, be given a copy and, if so, under what conditions? Because some staff are supervisors, consider talking with them about the elements to include when documenting employee actions associated with Risk Management continued from page 16 Sample Health Center Staff Documentation Policy NURSING documentation addresses these elements. Some nurses may prefer to use the acronym SOAPIE (subjective, objective, assessment, plan, implement, evaluation) to guide their charting process. At minimum, the expectation is that each element is addressed when charting. 1. Information from the client or family (subjective) — use quotation marks to identify quotes from the client. 2. Factual, measurable data gathered during the assessment process (objective data). 3. Conclusions based on the collected data, both objective and subjective, formulated as a client problem or nursing diagnosis (assessment). 4. A strategy for addressing the client problem that includes outcome expectations (the plan). 5. A description of what was done to achieve the outcome (nursing intervention or implementation). 6. A statement about the effectiveness of that intervention or, if the outcome was not as expected, a revision of the original plan of care (evaluation). WILDERNESS FIRST AID (WFA) credentialed staff document to the following standards: 1. The date and time of the client contact. 2. The legal name of the injured person (this may be ignored if charting directly on the client’s health record). 3. A description of the incident (what happened). 4. A description of the signs and symptoms that includes objective information (e.g., size, location, color, temperature) as well as comment from the client. 5. A description of the provided first aid. 6. Summary of the follow-up instructions given to the client. 7. Note to whom this injury-illness event was reported (e.g., village nurse). PROVIDERS WITH OTHER CREDENTIALS document in a manner that (a) reflects the practice of that discipline and (b) is appropriate to the provider’s scope of practice. Minimal expectation is as described for the WFA credential. Optimal documentation reflects what is expected of nurses.
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