Documentation

Guidelines for Computerized Documentation and Electronic Medical Records (EMR)

-Never give your pw to anyone -Don't leave comp terminal unattended -Follow protocol for correcting errors -Never create, change or delete records unless you have authority to do so -Back-up files -Don't leave info displayed on monitor -Never use email to send protected health info -Follow agency's confidentiality procedures

Medicare Requirements for Home Health

-homebound, still needs SNF care -rehab potential is food or pt is dying -pt not stabilized -pt making progress in expected outcomes of care

Computerized Documentation Advantages

1. Calls up admissions assessment tool and keys in pt data 2. Develops care plan with NANDA dx 3. Adds to pt database 4. Receives work list with tx, procedures, and meds throughout shift 5. Documents care STAT

Purpose of Patient Records

1. Communication with other healthcare professionals: continuity of care 2. Recording diagnostic and therapeutic order: nurse responsible for ensuring orders are entered in record and implemented, carry orders of licensed personnel only 3. Care planning: monitor day to day for changes 4. Quality Review: reviewed to evaluate quality of care and competence of nurses, agencies can randomly pick charts to check 5. Research: learn how best to recognize or treat identified health problems 6. Decision analysis: administrative planners read data needed to identify needs and the means and strategies most likely to address these needs 7. Education: learn about clinical manifestations or health problems, effective tx modalities and factors 8. Legal documentation: used as evidence in court proceedings, or accident/injury claims 9. Reimbursement: proof of care received to payers 10. Historical documentation: can be pertinent in future

Documentation Guidelines

1. Content: current, facts, nursing process, responsibilities, avoid general words, chronological order, precautions, preventative measures, medical visits, consultations, time and response of PCP, no stereotypes or derogatory terms 2. Timing: date, military time, nursing interventions near time after carried out, progress note at admissions, transferring, discharging, postoperative, postprocedure, critical info to PCP, change in status 3. Format: Correct chart, dark ink, grammar, spelling, date and time each entry, never skip lines, draw line through blank spaces 4. Accountability: sign with first initial, last name, title, single line through errors, "mistaken entry" or "error in charting" next to wrong entry and sign, check patient's name and ID # 5. Confidentiality: privacy, no patient names on written or oral reports

Permitted Disclosure of PHI

1. Public health activities EX: disease outbreak, infection control, stats 2. Law enforcement and judicial proceedings EX: prosecution of crime, identify victim, child abuse or neglect, valid subpoena 3. Decreased individuals EX: coroners, medical examiners, funeral directors, organ donation, law enforcement for death of potential crime

Types of Orders

1. Verbal: during emergency - directly from PCP to RN or pharmacists, record in pt medical record, read back order to verify accuracy, date and time, VO, name of PCP, nurse's name and title - PCP will verify and sign, title, pager later - RN checks transcribed correctly 2. Telephone and Fax: transcribed on order sheet, another nurse can listen too, faxes must be legible -PCP referred to house officer, RN, or pharmacist -record in medical record, read back, date and time, TO, name and title of PCP, RN sign name and title

Source-Oriented Records

Agency keeps data on own separate form, chronological order with most recent in front Cons: fragmented data Progress notes: notes written to inform caregivers of progress towards achieving expected outcomes Narrative notes: from RN, includes routine care, normal findings, problems identified

Confidential Info

All patient info that is written, spoken, and saved on a computer EX: name, address, SSN, reason person is sick, tx, PMH Breaching EX: over the phone with spouse, on the way to lunch with another caregiver who knows the pt but not involved in care, discussing info in public area, unattended computer, sharing pw, copying data, improperly reviewing record out of curiosity, leaving voice mail, using pt name in oral or written report for school

Focus Charting

Bring focus of care back to pt and pt concern on pt strength, problem or need Uses DAR format: data, action, response Pro: holistic emphasis on pt and pt priority, easy charting Con: not helpful when documenting care

Change-of-Shift Reports

By primary nurse to nursing replacing him or her, CN to nurse who assumes responsibility for continuing care, written/oral -basic identifying info about each pt: name, room, dx, PCP -current appraisal of each pt status: change in status, data, abnormal findings, nursing dx and goal -current orders: changes, upcoming or ongoing tests -abnormal occurrences during shift -unfilled orders -reports on pt dc and transferred

Kardex and Patient Care Summary

CP that communicates conveniently and concisely the plan of nursing care, recorded on folded card and placed in central Kardex file, eventually placed in pt health record Outside card: profile, diagnosis, orders for activity level, diet, VS, diagnostic test, meds, tx Inside care: nursing CP with nursing diagnosis and health problems, outcomes, interventions, safety precautions

Reports to Family

Clarify with pt who will get report, can use a password to access report over the phone, when pt cannot express objections then use best judgment

Health Insurance Portability and Accountability Act (HIPAA)

Congress passed in 1996 but regulations released in 2000 and modified in 2002 to protect patient privacy Patients have right to: 1. See and copy their health record 2. Update their health record 3. Get list of disclosures made for purposes of tx, payment, and operations 4. Request restriction on certain uses of disclosures 5. Choose how to receive health info "If a health institution wants to release a pt's health information for purpose other than tx, payment and routine health care operations, the pt must be asked to sign an authorization"

Consultations and Referrals

Consult: inviting another professional to evaluate pt and make recommendations to you about tx Referral: sending or guiding pt to another source for assistance

Long-term Care Documentation

Definitive info on pt strengths and needs and addresses these in care plan Monitored by Resident Assessment Instrument (RAI), tracks changes in pt status by evaluating goal achievement and making appropriate revisions in care plan, wants highest level of functioning and sense of individuality Components of RAI: -minimum data set: communication about pt problems and conditions -triggers: pt response to minimum data set -resident assessment protocol:organization of minimum data set info, identify social, medical, nursing problems -utilization guidelines: when and how to use RAI from operation manual Benefits of RAI: residents respond, staff communication, family involvement, clearer documentation

PIE Charting: Problem, Intervention, Evaluation

Does not develop a separate care plan, incorporated into progress notes Pro: promotes continuity of care, saves time Con: no formal care plan so RN must read all notes to determine problem and planned interventions

Case Management Model

Emphasis on quality, cost-effective care Pro: collaboration, communication, teamwork, efficient use of time, quality Con: best for typical patients with few individualized needs Collaborative pathways: specifies plan of care linked to expected outcomes along timeline, part of computerized documentation system Variance charting: charting pt failure to meet outcome or planned intervention not implemented; includes unexpected event, cause of event, actions taken, and dc plan, usually because of quality, cost or length of stay

Telephone/Telemedicine Reports

Enable receiving and giving critical info in timely fashion -identify yourself, pt, and relationship to pt -report concisely and accurately in change of pt condition and what has already been done in response to this condition -current VS and clinical manifestations -pt record in hand -time and date of call, info communicated to PCP, PCP response

SBAR

Framework for reporting Situation: communicate what is occurring and why pt is being handed off to another department or unit Background: explain what led up to current situation and put in context Assessment: give impression of problem Recommendation: what you would do to correct problem

Outcome and Assessment Information Set (OASIS)

Group of data elements that represent core items of comprehensive assessment for adult home care pt and form basis for measuring pt outcomes for purposes of outcome-based quality improvement Useful for outcome monitoring, clinical assessment, care planning for Medicare

Nursing Care Rounds

Group or nurses visit selected pts at bedside, gather info to help plan nursing care, evaluate nursing care, provide pt with opportunity to discuss care, give pt short summary of DPI from ADPIE, use language pt can understand

Nursing Informatics

Includes nursing science, computer science, and info science to manage and communicate data, info, and knowledge in nursing practice Facilitates integration

Problem-Oriented Medical Records (POMR)

Originated from Dr. Lawrence Weed in 1960s Organized around pt problem rather than sources of info Pro: entire healthcare team works together in identifying master list of pt problems and contributes collaboratively to plan of care Uses SOAP format: subjective data, objective data, assessment, plan

Initial Nursing Assessment

Record initial database from nursing history and physical assessment

Personal Health Records (PHRs)

Records on web to manage healthcare Pro: provide easy access to up-to-date info, assist in self-care, communication with PCP and caregivers Con: cost, concern for privacy, inconvenience, design shortcoming, inability to share info across organizations

Flow Sheet

Records routine aspects of nursing care 1. Graphic/Clinical Record: records specific patient variables such as VS, weight, fluid I&O, BM 2. 24-hour Fluid Balance Record: documents 24-hour fluid I&O 3. Medication Record: all meds administered, med nurse, reason drug administered and its effectiveness 4. 24-hour Patient Care Records and Acuity Charting Forms: can quickly document routine aspects throughout 24-hour period, rank high-to-low acuity in relation to both pt condition and need for nursing assistance, determines staffing requirements

Home Healthcare Documentation

Reports pt progress, sent to PCP with request for medical orders to continue tx, ensure continuity of care, continued reimbursement for services

Incidental Disclosure of PHI

Secondary disclosure that cannot reasonably be prevented, limited in nature, and occurs as byproduct of otherwise permitted use or disclosure of PHI 1. Sign-in sheets without reason for visit 2. Possibility of confidential information overheard in appropriate surrounding where conversation kept down 3. Charts outside exam room where traffic not permitted 4. White boards with min info 5. X-ray light boards without unattended x-rays 6. Calling out names in waiting room without reason for visit 7. Leaving appointment reminder voice mail with min info

Charting by Exception (CBE)

Shorthand documentation method making use of well-defined standards of practice, documents significant findings or exception in narrative form Pro: decreased charting time, emphasis on significant data, timely bedside charting, standardized assessment, greater interdisciplinary communication, tracking important pt response, lower costs Con: limited usefulness when trying to prove high-quality safe care in response to negligence claim made against nursing

Transfer and DC Reports

Summarize data that caregivers need to provide immediate care

Discharge and Transfer Summary

Summary with reason for tx, significant findings, procedures, condition on dc or transfer, pertinent instructions

Nursing and Interdisciplinary Team Care Conferences

Used for instructing students and practitioners, meeting of nurses to discuss some aspect of pt care

Incident Report

Variance or occurrence report to document anything out of ordinary resulting in or has potential to result in harm to pt, employee, or visitor, used for quality improvement Helps with quality and improvement, not for legal purposes