Documentation of Medical Procedure

  • Medical procedures such as g-tube feeding and suctioning must be documented on the Daily Procedure Log.
  • A Sample Daily Procedure Log is provided to guide staff on how to document on the form.
  • Catheterization of a student needs to be documented on the Catheterization Log. A blank sample is included in this section.
  • Any medical procedure that includes the administration of medication, as part of the procedure, also requires documentation on the Student Medication Log. For example, if a student has an order to receive a nebulizer treatment, the treatment is documented on the Daily Procedure Log and the medication is documented on the Student Medication Log. See Section on Medication Administration for copy of log.
  • Blood Glucose Monitoring must be documented on the Daily Diabetic Log and. See Section IX – Medication Administration for a copy of the Daily Diabetic Log.
  • Personnel performing medical procedures need to also document any abnormal findings/concerns and/or any communication with parent or guardian under the Notes section on the back of the Daily Procedure Log and Daily Diabetic Log.
  • Remember, when documenting on these forms you may not use white out or correction tape. If you make an error, cross it out with a single line and date and initial it. Then document the correct information. Provide any additional important information on the back of the procedure log.
  • In the event an entry onto the log is missed, the authorized person who omitted the notation is to document “Late Entry” and the current date the notation was made on the back of the log under Notes. For example, if it were realized on October 2nd that a procedure that was given on October 1st was not documented, the authorized person would place their initials on the front of the log under October 1st and circle them. On the back of the log, under notes, the individual would write the date October 2nd Late entry: “Procedure was administered on October 1 as ordered” and sign name.
  • When a treatment/procedure is discontinued a red line should be drawn through the name of the procedure on the Student Daily Procedure Log. The date and the initials of the person discontinuing the procedure should be placed next to the name of the procedure. A notation is to be made on the back of the log as to the date and the name of the parent/guardian who requested that the procedure be discontinued. If there are no other procedures to be performed the forms should be placed in the student’s Cumulative Health Folder.
  • All schools have either On-Site School Health Personnel (Nurse or Health Support Technician) or a Department of Health-Broward On-Call nurse to assist with any concerns.
  • All logs should be kept in a locked cabinet in a secure place, preferably the school clinic. All procedure logs will need to be filed in the student’s Cumulative Health Record by the end of the school year.