Chapter 9: Recording and Reporting

List 4 types of written forms

- Nursing care plan- list of client's problems, goals, and nursing orders for client care -Nursing Kardex- quick reference for current information about client and client care. -Checklists-documentation with check mark or initials -Flow sheets- Documentation with sections for recording frequently repeated assessment data.

What other way can you communicate?

-Change of shift reports -client assignments -team conferences -rounds -telephone calls

List workplace applications that HIPPA legislation has created

-Client names on charts no longer visible to public -All clipboard must obscure private client data, including name -Whiteboards cannot link client name with diagnosis, procedure, or treatment -Computer screens not visible to public; flat screen monitors recommended. -Conversations regarding clients must occur in private places -Fax machines and medical records must be limited to areas inaccessible to public -Cover sheet on all faxes; emails warning that confidential information being transmitted -Light boxes (for x-ray, scan results) must be located in private areas. -Documentation must be kept on all with access to client records.

What are some uses of medical records?

-Permanent account -Sharing information -Quality assurance -Accreditation -Reimbursement -Education and Research -Legal evidence

What are some components of medical records?

-Person's health information -Care provided by health practitioners -The client's progress -The plan for care -Medication administration record -Laboratory and diagnostic reports

Abbreviations

-Shorten length of documentation and documentation time. -Agencies provide list of approved abbreviations and their meaning -Use only abbreviations on agency's approved list. - Use Joint Commission "Do Not Use" list to avoid and reduce medical errors.

List the aspects of documentation

-Type of information recorded -the people responsible for charting -The frequency for making entries on the record -the type of response given for the information recorded.

Health Insurance Portability and Accountability Act (HIPAA)

legislation that sets national standards for the security of health information, ensures that an individual's electronic, paper, or oral health information is protected

auditors

inspectors who examine client records

Team conferences

-commonly used to exchange information. -topics include client care problems, personnel conflicts, new equipment or treatment methods, and changes in policies or procedures. -often include the nursing staff, staff from other departments involved in client care, physicians, social worker, personnel from community agencies and in some cases, clients and their significant others.

Client Care Assignments

-made at the beginning of each shift -assignments are posted, discussed with team members, or written on a worksheet. -assignment identifies the clients for whom the staff person is responsible and describes their care.

When a client voices concern with a nurse about keeping his medical information confidential, which situation is the nurse correct in identifying as one exception to maintaining confidentiality?

A. Confidentiality can be breached when a client has attempted suicide B. Confidentiality can be breached when a client has a substance abuse problem. C. Confidentiality can be breached when a client wished to terminate further treatment D. Confidentiality can be breached when a client has a highly contagious disease. D

When electronically documenting at the bedside of a client, which nursing actions are most appropriate? (select all that apply)

A. Logging on and off when entering data B. Returning the screen to the main menu C. Making entries in other clients records D. Asking others to leave while making an entry E.Turning the computer off before leaving A and B

When a nurse recognizes he or she has made a mistake when documenting written information, what actions are appropriate? (Select all that apply)

A. Obliterate the incorrect information with a black marker B. Draw a single line through the incorrect information C. Erase the misinformation so it is no longer readable D. Specify the nature of the incorrect information. E. Discard the page and rewrite the entire documentation. F. Initial and date the error, rewrite the correction. B, D and F

Which charting method involves writing information about the client and client care in chronologic order?

A. SOAP B. PIE C. Narrative D. Focus C. Narrative charting involves writing information about the client and client care in chronologic order. SOAP charting involves documenting client data under four essential components. Focus charting is a modified form of SOAP charting. PIE charting is a method of recording the client's progress under the headings of problem, intervention and evaluation.

checklist

form of documentation in which the nurse indicated with a check mark or initials that routine care has been preformed

flow sheet

form of documentation that contains sections for recording frequently repeated assessment data

When a nurse reviews the documentation of a nursing team member who has just been hired, which one of the following practices is most important to correct?

A. The newly hired person documents in a partially filled space. B. the newly hired person charts information at 2 hour- intervals. C. The newly hired person uses abbreviations in the documentation. D. The newly hired person signs an entry with first and last name and title. A

Which of the following nursing actions violates the Health Insurance Portability and Accountability Act (HIPAA)?

A. The nurse assigns five clients equally to each person on the team B. The nurse writes the names of clients on a dry erase board in a public area. C. The nurse posts the names of the assigned staff in the client's room D. The nurse reviews the Kardex of each client during a shift report. B

True or False: A nursing kardex is a documentation with sections for recording frequently repeated assessments.

False- Nursing Kardex is a quick reference for current information about client and client care.

True or false: medical records cannot be shared among health care workers

False- medical records are a means to share information among health care workers to ensure client safety and continuity of care.

narrative charting

Involves writing information about the client and client care in chronologic order. Content resembles a log or journal. It's time consuming to write and read.style of documentation generally used in source-oriented records.

Documentation Time

Military time- based on 24 hour clock; uses different four-digit number for each hour and minute of the day.

Name 6 charting methods

Narrative charting, SOAP charting, focus charting, PIE charting, charting by exception, and computerized charting

SOAP charting

S: Subjective Data O: Objective Data A: Analysis of the data P: plan for care format tend to focus the documentation on pertinent information that is required bu the Joint Commission. SOAP charting helps demonstrate interdisciplinary cooperation bc everyone involved in the care of a client makes entries in the same location in the chart documentation style more likely to be used in a problem-oriented record

Permanent account

The client's medical record is a written, chronologic account of a person's illness or injury and the care provided from the onset of the problem through discharge or death. The record is filed and maintained for future reference.

Sharing information

The documentation serves as a way to inform others about the client's status and plan for care. It also prevents duplication of care and helps reduce the chance of error or omission. Ex; client requesting pain meds, the nurse checks the client's current record to determine when the last pain med was administered. another ex; immunization records.

Accreditation

The joint commission established criteria reflecting high standards for client safety and institutional health care. They periodically inspect health care agencies to determine whether they demonstrate evidence of quality care.

beneficial disclosures

an exemption whereby an agency can release private health information without a client's prior authorization

Reimbursement

auditors survey medical records to determine whether the care provided meets the established criteria for reimbursement. Undocumented, incomplete, or inconsistent documentation of care may result in denial of payment

chart

binder or folder that enables the orderly collection, storage, and safekeeping of a client's medical records

informatics

collection, storage, retrieval, and sharing of recording data

change-of-shift report

discussion between a nurse from the shift that is ending and personnel coming on duty. -includes a summary of each client's condition and current status or care.

charting by exception

documentation method in which only abnormal assessment findings or care that deviates from the standard is charted. It provides quick access to abnormal finding because it does not describe normal and routine information.

electronic charting

documenting client information with a computer. Most effcient for nurses when documentation is done at the point of care (POC) on a bedside computer or a computer on wheels (COW)

Legal evidence

medical records are considered a legal document. Therefore, entries in medical records must follow legally defensible criteria. Portions of the medical record can be subpoenaed as evidence by the defense or prosecuting attorney to prove or disprove allegations of malpractice. Especially important to document safety precautions taken to protect the client, individuals who were notified about concerns and issues, and outcomes of the communication. Each person who makes entries in the client's medical record is responsible for information he or she records and can be summoned as a witness to testify concerning what has been documented.

PIE charting

method of recording the client's progress under the headings of problem, intervention and evaluation. -Similar to the SOAPIE format. PIE style prompts the nurse to address specific content in a charted progress note. -When nurses use the PIE method, they document assessments on a separate form and give the client's problems a corresponding number. They use the numbers subsequently in the progress notes when referring to interventions and the client's responses.

SBAR format

model for effective communication identifying Situation, Background, Assessment, and Recommendation

focus charting

modified form of SOAP charting. uses the word focus rather than problem bc some believe that the word problem carries negative connotations. Instead of using the SOAP format to make entries, focus charting follows a DAR model (D: data, A:action, R: response) DAR notations tend to reflect the steps in the nursing process.

minimum disclosure

portions or isolated pieces of information necessary for an immediate purpose

charting

process of entering information

documenting

process of entering information

continuous quality improvement

process of promoting care that reflects established agency standards

quality assurance

process of promoting care that reflects established agency standards

total quality improvement

process of promoting care that reflects established agency standards

recording

process of writing information

Education and Research

published reference are primary resources for health education. Examining the medical records of clients with specific disorders, however, provides a valuable supplement that enhances learning and future problem-solving. Ex: some types of clinical investigations are difficult to conduct because few participants are in a particular locale or test facilities are limited. Consequently, stored, microfilmed or EHR's serve as an alternative resource for scientific data. To protect confidentiality, only authorized persons are allowed access to client records. Formal permission must be obtained from the client, the health agency's administrator, or other authority whenever a client's record is used for a purpose other than treatment or record keeping.

Kardex

quick reference for current information about the client and the client's care

problem-oriented record

records organized according to the client's health problems

source-oriented record

records organized according to the source of information

double charting

repetitious entry of the same information in the medical record

military time

time based on a 24- hour clock

traditional time

time based on two 12-hour revolutions on a clock

Quality assurance

to maintain high level of care, hospitals and other health care agencies use medical records to promote quality assurance (QA), continuous quality improvement (CQI), or total quality improvement (TQI) (an agency's internal process for self-improvement to ensure that the level of care reflects or exceeds established standards).

Telephone calls

use the telephone to exchange information when it is difficult for people to get together or when they must communicate information quickly.

rounds

visits to clients on an individual basis or as a group - used as a learning firsthand about clients -as a group, client is a witness to and often an active participant in the interaction. -tends to boost client confidence and security in their care. -agencies avoid this type of communication if another client shares the room or if the client has not authorized family members or friends who may be visiting to have access to his or her health information.

medical record

written collection of information about a person's health problems, the care provided by health practitioners, and the progress of the client

nursing care plan

written list of the client's problems, goals, and nursing orders for client care