FPCC- Pt id, confidentiality & Documentation
Do not use abbreviations
"U" or "u"- Unit "IU"- International Unit Q.D., QD, q.d., qd- Daily Q.O.D., QOD, q.o.d., qod- every other day MS, MSO4, and MgSO4 either morphine sulfate or- magnesium sulfate The trailing zero for medications (X.0 mg)- X mg (e.g., 10 mg) Lack of leading zero (.X mg)-0.X mg (e.g., 0.1 mg)
handoff report
(sometimes called a change-of-shift report or handover report) is to promote continuity in care. The nurse is alerted to the client's status, recent status changes, planned activities, diagnostic tests, or concerns that require follow-up. A handoff report may be given at the bedside or in a conference room, using paper notes or an EHR device.
can you delegate charthing?
- No In some facilities, each member of the team is responsible for documenting care provided to the client. Nursing assistants or other unlicensed assistive personnel (UAP) often document ADLs, activity, and I&O on graphic records. You are responsible for documenting the nursing care you provide. Never document the actions of others as though you performed them. If an action is crucial to a chain of events, you may document that action on paper or in the EHR, clearly referring to the person who did the action. For example, "Became dizzy; assisted to chair by Nora Roverdale, UAP."
Patients are always identified by at least _______ identifiers, neither of which is the _______ _______.
-2 identifiers -Never use patient's room number or -Is your name?... Older people may get confused and say yes incorrectly. -Say instead, Please tell me your name.
When do you confirm your patient's identification?
-Before giving meds. -Before doing anything with your client. When you first walk in the room.
You must carry out the order if the provider does not change it? True or False
-False -If you believe a prescription is inappropriate or unsafe, you are legally and ethically required to question the prescription.
Who is contacted when you feel that an order needs to be questioned?
-Generally, you should contact the provider who wrote the prescription. -As a student, you will first want to discuss your concerns with your clinical instructor or the nurse you are working with during your clinical time.
HIPPA
-Health Insurance Portability and Accountability Act ■ Protect health insurance benefits for workers who lose or change their jobs ■ Protect coverage to persons with preexisting medical conditions ■ Establish standards to protect the privacy of personal health information
when should you question an order?
-If you feel uncertain about a prescription, you must question it -If a prescription is written illegibly on paper or is entered into the EHR missing certain details or components, contact the provider directly for clarification.
When can you skip confirming patient ID?
-Never. Never skip this step. -Never skip this step, even if you are familiar with the patient. If you are busy and distracted, it is possible to enter the wrong room.
I & O (Intake and output) records
-You will enter data about the patient's fluid balance on a separate intake and output (I&O) form or flow sheet. Electronic systems have flowsheet sections or I&O forms to enter I&O and save it into the patient's EHR (see Fig. 18-2). I&O is totaled by shift and by 24-hour periods. Paper forms must be totaled manually, whereas electronic systems usually automatically total I&O figures for you. I&O paper graphics may be kept at the bedside, or you might input the I&O totals at the bedside using an electronic device (e.g., tablet). For a paper record, see Figure 3-3. -If your patient or a family member is able to assist with measuring his I&O, teach him how to track his own intake and output on the paper record. Nevertheless, you will need to enter the patient's I&O data into the EHR. Chapter 28 provides detailed information about monitoring intake and output.
Checklists
Assessments and care may also be recorded on paper and electronic checklists. Common normal and abnormal findings are usually organized according to body systems. Figure 18-6 is an example of a paper checklist. ■ Using a paper form, the nurse checks the box that reflects the current assessment findings. Some checklists include nursing actions, such as wound care, treatments, or IV fluid administration. Essentially these forms are used to promote comprehensive documentation. Client care activities, responses, and exceptions (deviations) are recorded in the narrative note section of the paper form. ■ Using an electronic field-based checklist, the nurse enters values or text in the appropriate fields and saves the documentation. Electronic flowsheets contain information similar to paper checklists, but also include a greater range of potential documentation areas that can be opened as needed (e.g., treatments, IV fluid administration, and other parameters).
what is a verbal order?
are spoken directions for patient care given to you in person, usually during an emergency. Providers should never use verbal communication as a routine method of giving prescriptions.
bedside report
A bedside report, sometimes known as "walking rounds," allows you to observe important aspects of care, such as appearance, IV pumps, and wounds. With a bedside report, the outgoing nurse can introduce you to the patient. If the patient is alert, give him the opportunity to participate in the report and ask questions. Although this type of report is time consuming, it encourages continuity of care, team collaboration, and client/family communications. Key Point: Ensure that the patient's privacy rights are protected when using bedside reports. -This is the expected approach in most facilities.
Paper Record Disadvantages
Access may be delayed. Only one care provider can access the record at a time; the provider must be in the same location as the chart. Retrieving information may be slow. ■ Healthcare providers may need to search through multiple pages to find needed information. ■ Specific documentation is difficult to retrieve when needed, especially when files are archived in another part of the building. Documentation is time-consuming. ■ Documentation may take more time because writing by hand is slower than computer entry. ■ Documentation is often redundant and repetitive. ■ Paper records require manual audit of many charts to create reports and collect client data. This is time- and resource-intensive. There is a relatively high risk for patient care error. ■ Narrative documents are hard to read if the handwriting is illegible or messy. This means nurses have to take time from patient care to contact providers to clarify handwritten prescriptions. ■ Papers can be lost from the chart or damaged, leading to duplicate assessments or medication errors. ■ Paper records are often inconsistent in how the same client information is documented, even within the same organization. Often standardized terminology is not used. Storage of paper records is expensive. Confidentiality is difficult to protect. There is no way to know who may have access to the paper health record without proper authorization.
how do you maintain confidentiality and data security
Although the specific risks to and safeguards of confidentiality differ in detail between paper and electronic records, confidentiality is equally important in both. The following safeguards are specific to EHRs: ■ Ensure confidentiality and privacy—Close the screen, lock the computer, or permanently log off of the EHR system when moving away from an open EHR. Most computer stations will automatically log off after a specified period of inactivity. This helps keep unauthorized viewers from having access to client information. ■ Use privacy filters—Some computer screens are equipped with privacy filters to prevent unauthorized viewers from seeing the information. ■ Create a secure password—not something obvious, such as your birth date, Social Security number, or family members' names. Instead, you might choose a password that is at least eight characters long and includes at least one capital letter (if the system is case sensitive), one number, and (if allowed by the system) one symbol. The system you are using will determine the specifications. ■ Change your password at regular intervals even if your organization does not require it. Some systems will lock you out of the system if your password is not changed as required. ■ Do not share your personal username or password with anyone. You are responsible for the data recorded using your electronic identity. If someone else enters data or accesses records under your identity, you may be held responsible if the client initiates legal action. ■ Do not leave client data displayed on the screen where others can see it. ■ Do not leave the computer unattended after you have logged on. This allows others access to confidential data and to document under your name. ■ Do not leave a portable device (e.g., a laptop or PDA) unattended in a public location, such as on a countertop in the nurses' station. This increases the possibility of theft or unauthorized access to secured client information. ■ Never access client health records that you have no professional reason to view. This is a severe breach of client privacy rules. Know your state and federal laws and the consequences for privacy violations. ■ Become familiar with your organization's policies regarding network and client health record information security and confidentiality
How Do I Maintain Confidentiality and Data Security?
Although the specific risks to and safeguards of confidentiality differ in detail between paper and electronic records, confidentiality is equally important in both. The following safeguards are specific to EHRs: ■ Ensure confidentiality and privacy—Close the screen, lock the computer, or permanently log off of the EHR system when moving away from an open EHR. Most computer stations will automatically log off after a specified period of inactivity. This helps keep unauthorized viewers from having access to client information. ■ Use privacy filters—Some computer screens are equipped with privacy filters to prevent unauthorized viewers from seeing the information. ■ Create a secure password—not something obvious, such as your birth date, Social Security number, or family members' names. Instead, you might choose a password that is at least eight characters long and includes at least one capital letter (if the system is case sensitive), one number, and (if allowed by the system) one symbol. The system you are using will determine the specifications. ■ Change your password at regular intervals even if your organization does not require it. Some systems will lock you out of the system if your password is not changed as required. ■ Do not share your personal username or password with anyone. You are responsible for the data recorded using your electronic identity. If someone else enters data or accesses records under your identity, you may be held responsible if the client initiates legal action. ■ Do not leave client data displayed on the screen where others can see it. ■ Do not leave the computer unattended after you have logged on. This allows others access to confidential data and to document under your name. ■ Do not leave a portable device (e.g., a laptop or PDA) unattended in a public location, such as on a countertop in the nurses' station. This increases the possibility of theft or unauthorized access to secured client information. ■ Never access client health records that you have no professional reason to view. This is a severe breach of client privacy rules. Know your state and federal laws and the consequences for privacy violations. ■ Become familiar with your organization's policies regarding network and client health record information security and confidentiality.
Principles of privacy and confidentiality are derived from the principle of ?
An autonomous person has control over the collection of, use of, and access to her personal information. clients share sensitive information with nurses that they would not share with others based on the nurse-client relationship. To maintain that trust, you should:
Key point: How does the nurse document the occurrence report in the EHR? trick question alert.
An occurrence report is not part of the client's health record and thus should never be referenced in the nurses' notes or in other sections of the health record. ■ The paper report is sent to risk management, according to agency protocol, whereas the electronic form is completed on the organization's secure internal network.
nursing process
Assessment: Chart signs and symptoms that may indicate actual or potential client problems. At an initial assessment, document comprehensive data about all client systems. Diagnosis/Analysis: After analyzing assessment data, document your clinical nursing judgment about the client's response to actual or potential health conditions or needs. Outcomes/Planning: Document measurable and achievable short-term and long-term plan of care with goals directed at preventing, minimizing, or resolving identified client problems or issues. Implementation: After putting the plan of care into effect, record the specific interventions that were used. Evaluation: Document client responses to nursing care; chart whether the plan of care was effective in preventing, minimizing, or resolving the identified problems; and then modify the plan as needed.
Documentation purposes
Communication Members of the interprofessional team use the health record to communicate about the client's status and care. For example, if it is not possible to speak directly to the respiratory therapist on your shift, you can at least review the progress notes. This documentation communicates essential information that enables healthcare professionals to plan and evaluate treatment and monitor health status over time. Continuity of Care Communication promotes continuity of care. For example, if you are concerned that the client is at high risk for infection, you can include a nursing diagnosis of Infection on the written or electronic plan of care. You would then initiate nursing prescriptions for other nurses to regularly observe for and document signs of infection. Quality Improvement To improve overall quality of care, healthcare agencies must identify ways to decrease length of stay, control costs, and identify knowledge and practice gaps that can be addressed through inservice and continuing education. In an internal review, they ■ Perform manual chart audits (directed reviews of client medical records) of written documentation. ■ Run reports to analyze large amounts of data in electronic health record (EHR) systems. External accrediting agencies, such as The Joint Commission, review written and electronic records to ensure delivery of quality care and public safety. Planning and Evaluation of Patient Outcomes Documentation enables providers, nurses, and other healthcare professionals to plan and evaluate treatment and monitor health status over time. Legal Record The health record will be scrutinized by legal experts if a dispute about a client's care arises. In court, the health record is legal evidence of the care given to a client and is used to judge whether the interventions were timely and appropriate. Expert reviewers look for documentation of the client's baseline status, changes in status, interpretation of the changes, interventions implemented, and the client's responses to those interventions. Professional Standards of Care The American Nurses Association (ANA) Scope and Standards of Practice (2015) includes documentation in many of its standards. If you want to know which specific standards include documentation, see Box 18-1. Reimbursement and Utilization Review Insurance companies, government and third-party payers, budget managers, and organization billing staff use client health records to determine the cost of care. They also use the health record for utilization review to determinate whether the medical treatments and interventions were necessary and appropriate.
CUBAN
Confidential Uninterrupted Brief Accurate Named Nurse
Discharge
Discharge data are obtained with the admission assessment, but are often recorded on a separate form. Key Point: A general principle in nursing is that discharge planning begins on admission. Therefore, discharge needs should be evaluated when the patient first enters a healthcare facility, especially in acute care facilities. Ask yourself what this patient would need if he were to go home in the next few days. For example, would he need help with food preparation? With his medicines? With his hygiene? A discharge summary can be started any time after admission and revised throughout the hospitalization in the electronic medical record. In contrast, it is the last entry made in the paper record. A summary is completed when the patient is transferred within the same organization or to another facility, or discharged to home. The discharge summary may be a multidisciplinary document or each discipline may write a separate summary. The forms are different in each organization, but they contain similar data.
Flowsheets/graphics
Document assessments and care that are performed frequently, on a recurring schedule, or as a part of unit routines (e.g., I&O, weight, hygiene measures, ADLs, and medications). ■ Perform and document care activities. How often you do so depends on your client's condition and the unit policy. In the first hour after surgery, for example, you would probably record vital signs every 15 minutes, then every 30 minutes for 1 hour, and then every 4 hours. ■ Allow you to see patterns of change in client status. For instance, you may view a steady increase in the line representing a client's blood pressure compared with his pain score on an electronically generated graph. On a paper form, you may scan across a row to see that your client has not had a bowel movement for several days.
Electronic health record (EHR) Disadvantages
Expense: Electronic documentation systems are expensive. ■ Downtime: Downtime processes must be in place for times when parts of the EHR are not available (e.g., because of power outages and system upgrades). ■ Difficulties associated with change: ■ Learning to use some documentation systems can be challenging and time consuming. ■ Some healthcare providers resist the change to EHR. ■ It is not easy to capture narrative nursing content from paper charting into an electronic format. ■ Some EHRs are not user-friendly (e.g., difficult to quickly find information needed to make care decisions). ■ Some systems do not control redundancy well, requiring caregivers to continuously ask the client for the same information. ■ Lack of integration: Most EHRs are not integrated across the different departments. This means that sometimes a person with a legitimate reason to enter the record cannot see entries made by other departments and must then request verbal, e-mail, or paper reports (e.g., lab results).
Charting
Key Point: A basic principle of charting is that a third person should be able to read your documentation and form a mental picture of your client and the care provided during your shift. You should document: ■ All interactions with clients, as well as the refusal of or noncompliance with treatment. ■ Telephone conversations with primary care providers, including time, content of the conversation and the action you took. ■ The facts; do not editorialize (e.g., do not write, "I could not check on the patient as often as prescribed because we
Why are telephone orders high-risk?
Telephone prescriptions can lead to errors because of differences in pronunciation, dialect, or accent; background noise; poor reception; and unfamiliar terminology. Taking a telephone prescription is not recommended but may be acceptable in the following situations:
What client identifiers are acceptable to the The Joint Commission?
The Joint Commission clarifies that acceptable patient identifiers can be the patient's name, assigned identification number or other agency specified person specific identifier and that the two identifiers may be in the same location, such as a wristband, electronic identification technology coding (e.g., bar coding)
SBAR
Identify yourself, the client, and the agency. Situation—"Here's the situation ..." Background—"The supporting background information is ..." Assessment—"My assessment of the situation is that ..." Recommendation—"I recommend that you ..." [Read back—"To repeat the information and ..."] [Questions—Questions asked and answered]
IPASS
Illness severity—describes the patient's illness acuity level Patient summary—a comprehensive overview of the patient (e.g., history, diagnostic test results) Action list—correlates with interventions (e.g., consultations, prescriptions, medications) Situation awareness and contingency plans—overall plan based on patient's response (condition deteriorates or improves) Synthesis by receiver—Confirmation of understanding; message sent is the message received
What is the cause of 30% of malpractice clams and how many patients deaths?
Inadequate communications during handoffs can contribute to adverse client events. One study found that communication failures contributed to 30% of malpractice claims, resulting in 1,744 deaths in U.S. hospitals (CRICO Strategies, 2015). Key Point: No matter where or how the handoff report is given, nurses should use a consistent, structured (standardized) process that contains critical key items, which has been shown to significantly reduce client care errors (The Joint Commission, 2017).
Be alert for patients with the same last name
It is common to have patients with same or similar last names (e.g., Williamson, Wilkinson, Wilson, Wilkerson). Look for and place special alerts on medical records and MARs to call attention to names that look or sound similar.
Medication Administration Record (MAR)
Medication administration records (MARs) contain information about the medications that have been prescribed for the client. The information and format vary by setting, with significant differences between outpatient and inpatient facilities. ■ Inpatient facilities. Inpatient medication records contain a list of prescribed medications and track their administration and usage for the agency. For a comparison of the content of inpatient and outpatient MARs, see Table 18-2. ■ Outpatient facilities (e.g., include clinics, primary care offices, and treatment facilities). Because patients do not stay at the facility, usually the MAR primarily contains information about how the patient is to use the medications prescribed. Patients retain responsibility for administering their own medications either independently or with the help of family or caregivers. -Some electronic MARs allow providers to look up detailed information about the medication, including indications, contraindications, expected and adverse effects, and safe dosage ranges based on routes of administration. Figure 18-7 is a portion of an electronic medication record. Figure 26-7 is a paper MAR.
narrative format
Narrative format is used with written source-oriented and problem-oriented charts. The narrative chart entry tells the story of the client's experience in the order that it happens. ■ It provides information on the details of the client's care—status, activities, nursing interventions, psychosocial context, and response to treatment. ■ It tracks the client's changing health status and progress toward goals. ■ Narrative charting is especially useful when attempting to construct a time line of events, such as a cardiac arrest or other emergency situations. ■ A disadvantage is that the lack of standardization can result in lengthy notes, making it difficult to retrieve relevant data in a timely manner (Blair & Smith, 2012). ■ A concern is that with the focus on EHR, clinicians may not read narrative notes despite their value in conveying essential information (Finn, 2015).
With whom will you share patient information? Be specific here! There are right and wrong answers.
Only people the patient as authorized you to do so. No over the phone. Only providers involved in the care of the patient at that time. Be careful what you day in the hallways etc.
PACE
Patient/Problem—Include client's name, room number, diagnosis, reason for admission, and recent procedures. State the present problem. Briefly summarize medical history relevant to the current problem. Assessment/Actions—Nursing assessments and interventions directed to the problem. Continuing/Changes—Continuing needs and potential changes include: ■ Client care and treatments that must be monitored on other shifts (e.g., dressing changes) ■ Changes in the client's condition or the care plan, recent or anticipated (e.g., new orders, changes in discharge date) Evaluation—Evaluation of responses to nursing and medical interventions, progress toward goals, and effectiveness of the plan
oral reporting
The purpose of giving an oral report is to maintain continuity of care, engage in professional communications, build team relationships, and collaborate to improve client care. Whether the source of the information shared is from a written report form, a paper Kardex®, or a summary in the EHR, the quality of the report you give and receive influences how you and others plan the shift work. Restrict your oral reports to client-focused discussion and limit unimportant details and social conversation.
What are some other words that we use that mean the same thing as documentation?
The terms documenting, recording, and charting are often used to mean the same thing
what's a transfer report
Transfer reports are given when a patient is transferred from unit to unit or from facility to facility. If the patient is being transported to another unit in the same facility, you will need to transport his paper chart unless the receiving unit can electronically access the medical record. Detailed information about the patient's health history can be communicated between healthcare professionals or transmitted before transfer. You should review your facility's policy about what can be copied or electronically transmitted during client transfers.
HIPPA Impact
Under HIPAA rules, healthcare agencies and their employees must take steps to ensure the confidentiality of the patient information and medical records. Nurses and other healthcare providers must protect the patient's right to privacy by not sharing their information with unauthorized individuals. In addition, HIPAA allows patients to see, make corrections to, and obtain copies of their medical records. The cases in the following box highlight the importance of understanding and complying with the safeguards created under HIPAA.
When should verbal orders be used?
You should accept verbal and telephone prescriptions only in specific situations when the primary care provider is not able to electronically submit, write, or enter them personally.
Admission
You will use admission forms in all settings—for example, in ambulatory clinics, long-term care facilities, and hospitals. The nursing admission form may be separate or a combined interdisciplinary form that is completed at the time the client enters the healthcare system. Accurate and timely completion of this form is essential because baseline assessment data: ■ Establishes a benchmark to monitor changes in the client's status; ■ Provides information about the client's support system and helps forecast future needs; ■ Contains critical information (e.g., presenting illness or reason for admission, vital signs, allergy information, current medications, ADL status, physical assessment data, and discharge planning information).
audio-recorded report
is a convenient, but sometimes time-consuming, way to transmit information. The outgoing nurse audio-records a report on his clients. This method does not allow you to ask questions about the client; occasionally, the audio quality is poor and the report is not clear. However, an advantage of this method is that the outgoing nurse continues to provide client care while the incoming nurse receives report. To minimize communication errors, the outgoing and incoming nurses should speak directly to each other to update information or answer any questions about the clients.
Documentation
is the act of recording patient status and care. The act of making a written record.
face to face oral report
may involve only the outgoing and oncoming nurse or may include the entire oncoming shift. When given in a conference room, an oral report does not let you directly observe the client, but it is time efficient and still allows interaction between nurses.
can you chart for another person?
no, only for yourself.
occurrence reports
or incident report, is a formal record of an unusual occurrence or accident. It is an organizational report that is used to analyze the event, identify areas for quality improvement, and formulate strategies to prevent future occurrences.
incident report
same as occurrence report and variance report
Cases of violations of a Patient's privacy
■ A nursing assistant was terminated and faced criminal charges for sharing information on the abuse of a client with Alzheimer's disease on Snap-chat. In another case, a nursing assistant spent 8 days in jail for posting graphic photos of elderly and disabled patients on Facebook. ■ A nurse was disciplined by her employer for discussing the HIV status of a patient that was overheard by the spouse and other clients. A monetary settlement was made with the patient. ■ A nurse practitioner was denied access to a facility's electronic health records and reported to the board of nursing for accessing the health records of her ex-husband without permission. ■ A pediatric nurse was fired for posting a series of comments about a hospitalized child with a rare case of measles that could have been prevented with vaccination. The information could have potentially identified the patient.
Paper record advantages
■ Care providers are comfortable with it because it is familiar. There is little "learning curve." ■ Paper records do not require large databases and secure networks to function. ■ There is no downtime for system changes, weather, and so on. ■ It is relatively inexpensive to create new forms and update old ones.
Important concepts of privacy and confidentiality
■ Discuss information relevant to client care in approved areas (conference rooms, bedside) and not in areas where others can overhear you (e.g., hallways, cafeterias, elevators). ■ Share information with team members who have a need to know based on their involvement in client care. ■ Obtain the client's consent before providing information to family members or friends. ■ Not post pictures of clients on social media sites. Even inadvertently capturing patients in photographs has led to harsh disciplinary actions against the nurse.
How will you document telephone orders
■ When writing on a paper prescription form, first document the date and time. Next write the text of the prescription. Following the text of the prescription, depending on how you received the prescription, write "TO" (telephone order) or "VO" (verbal order), followed by the prescribing provider's name and then your name. The following is an example of a telephone prescription: 12/17/20 0815——Morphine 2 mg IV push ×1 for pain now. TO Dr. Clayton Kent/Sarah Hogan, RN; prescription read back for verification and validated. ■ Sign electronically to activate the prescription. If entering the prescription electronically, indicate during entry that it was given verbally or over the telephone, the date and time the prescription was given, and then search for and select the prescribing provider's name. Click "sign" or whatever option in your EHR indicates the prescription is signed and is now active. ■ Be sure you have the provider's phone number so that you can reach him or her if questions arise in the future. ■ All verbal and telephone prescriptions must be countersigned by the provider within 24 hours or according to agency policy.
Electronic health record (EHR) Advantages
■ Enhanced communication and collaboration. Communication is improved among healthcare providers. ■ Improved access to information. ■ Multiple healthcare providers can access the same information at the same time. ■ Authorized persons can access information remotely (e.g., from a client's home). ■ EHRs integrate client information between multiple departments so that new information is immediately available to users in all areas. For example, when the laboratory enters a critical result, such as a clotting time, you do not need to wait for the lab to phone or e-mail result to the nursing unit. ■ Time savings. ■ Nurses spend up to 25% less time charting. ■ Stored information is quickly and easily retrieved. ■ Reports can be created quickly because of the computer's ability to aggregate data (e.g., a 24-hour graph of the patient's vital signs). ■ Repetition and duplication are reduced. ■ Improved quality of care. ■ The system can use protocols to automatically enter prescriptions based on the client's condition. For example, some EHR systems will automatically enter a prescription to observe and document risk of falls when a client's "falls score" exceeds a certain level. ■ Embedded protocols enhance caregiver knowledge and the ability to follow clinical practice guidelines. For example, suppose there is a medical prescription to administer insulin based on a client's blood glucose results. In some EHR systems, the nurse can activate an immediate link to the tables of information needed to decide how much insulin to give to the patient. Medical errors are minimized by programmed alerts that are automatically displayed when a provider takes an action that could be harmful (e.g., when a provider prescribes a drug to which a client is allergic). ■ Data can be analyzed at the time of collection, making immediate nursing decision making possible. ■ EHRs facilitate evidence-based practice by analyzing thousands of records in ways that cannot be done with paper forms. With aggregated data, nursing practice can be compared across populations and geographic locations to support nursing decisions and guide professional and organization quality improvement. ■ Information is private and safe. ■ Information is permanently stored and not likely to be lost. ■ Confidentiality of client information is enhanced by restricting access, tracking everyone who accesses the healthcare record, and using proper security clearances, unique passwords, and front-view screen protectors.
What should be done when receiving a verbal prescription or test result by phone?
■ Have a second nurse listen to the prescription, if possible, to verify its accuracy. ■ Write or enter the prescription electronically only if you heard it yourself; no third-party involvement is acceptable. ■ Repeat the written prescription even if you believe you have clearly understood it. ■ Spell unfamiliar names when repeating to be sure the spelling is correct. ■ Pronounce digits of numbers separately. For example, instead of "seventeen," say "one, seven." Mishearing a number can lead to a serious error in medication dosage. ■ Make sure the prescription makes sense, given the client's current status. ■ Transcribe the prescription directly into the medical record as quickly as possible. Writing it on a piece of paper and then copying it again onto a paper prescription form or into an electronic health record (EHR) can introduce an additional chance of error. If entering into an EHR, it is best to have the EHR's prescription entry area open and begin entering the prescription as the prescriber dictates it to you. ■ Write the prescription while the prescriber remains on the telephone or in the building so that you can ask any necessary questions immediately without the need for a return call.
If you refuse to carry out an order, what must you do?
■ If, after contact, the provider leaves the prescription as is and you still don't feel comfortable with it or believe there is an error, you may refuse to implement it. Also: ■ Inform the chain of command at your organization about your refusal. ■ Usually you will speak with the charge nurse, who may then contact the nurse manager or nursing supervisor. ■ The nature of the prescription will determine how this situation is handled. ■ If you do refuse to follow a prescription, you must document your refusal and the actions you took to clarify the prescription.
10 guidelines for paper health records
■ Maintain confidentiality. Do not provide written or verbal information to anyone not involved in the direct care of the client without the patient's consent. ■ Ensure you have the correct form (e.g., I&O sheet, graphic record) before you begin writing. ■ Check that the medical record and documentation forms are clearly marked with the client's name and identification number. ■ Write legibly, neatly, and in an organized manner. This enables others to read your entries and use them to make clinical decisions. Sloppy or illegible handwriting creates errors or, at least, leads to poor communication. ■ Always use black ink for handwritten notes (some agencies do permit blue ink). Inks other than black or blue are not legible when a patient record is photocopied. Do NOT use green or red pen. Remember that the patient record is a legal document. ■Do not leave blank lines in the narrative notes. If you need to leave space for clarity, draw a straight line through the area and begin on the next line. Open areas leave an opportunity for later tampering. ■ Draw a line through the incorrect charting and initial it. Never use a correction fluid, "ink over," or otherwise cover up written notes. ■ Sign all your paper documentation entries with your first name, last name, and professional credentials, such as Judy Long, RN. ■ Don't write in "shorthand" or use your own abbreviated symbols. ■ Use only abbreviations that are approved by your organization.
Examples of events requiring occurrence reports
■ Patient fall or other injury ■ Medication error ■ Incorrect implementation of a prescribed treatment ■ Needlestick injury or other injury to staff ■ Loss of patient belongings ■ Injury of a visitor ■ Unsafe staffing situation ■ Lack of availability of essential patient care supplies ■ Inadequate response to emergency situation
3 different standardized reports
■ The IPASS format is a multifaceted approach that promotes sustained improvements over time. The acronym stands for Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver (The Joint Commission, 2017). ■ The PACE format is one example of a standardized approach developed specifically to organize patient data in handoffs. The acronym stands for Patient/Problem, Assessment/Actions, Continuing/Changes, and Evaluation (Schroeder, 2006). ■ The SBAR (Situation-Background-Assessment-Recommendation) is an easy-to-remember, concrete acronym that is useful for framing any conversation. Because nurses and providers communicate in markedly different ways, SBAR is useful for interprofessional communication, especially critical situations requiring a clinician's immediate attention and action. SBAR allows for an easy and focused way to set expectations for how and what will be communicated between team members. The SBAR technique can be adapted for handoff reports.
what's included in an occurrence report?
■ When completing an occurrence form, be sure to: ■ Clearly identify the client, date, time, and location. ■ Briefly describe the incident in objective terms. ■ Quote the client or persons involved if possible. ■ Identify any witnesses to the event, equipment involved, and environmental conditions. ■ Avoid drawing conclusions or placing blame. Document actions taken and the client response to the interventions.
When is receiving a phone order acceptable?
■ When there has been a sudden change in your client's condition, and the provider is not in the hospital or cannot transmit prescriptions electronically. ■ In a life-threatening emergency—but you must apply the "document and read-back" safeguard.
what's in a transfer report
■ Your name, facility, and phone number ■ Client's name, age, gender, and admitting and current diagnoses ■ Client's providers(s), if still following client ■ Procedures or surgeries performed ■ Current medications and last date/time each was taken/time next dose is due ■ Client status at present as well as progression since admission ■ Last set of vital signs, plus any pertinent trends since admission ■ Tubes in place, such as IV lines, catheters, drainage tubes, along with the intake and output of each tube or drain ■ Presence of wounds or open areas of the skin plus current interventions for each ■ Names and contact numbers for family and significant others ■ Special directives, such as code status, presence of advance directives, preferred intensity of care, or isolation required ■ Reason the client is being transferred ■ Location of above information (on transfer form, in medical records, etc.)
