Ch 19 - Documenting and Reporting

Ask Yourself:

- "What would I want if it were my medical information in question?" - Need-to-know rule: "Do I really need-to-know this information in order to do my job?" Most of the time, if you have to ask, you probably don't need-to-know.

Nursing Documentation - initial nursing assessment

- Admission database for patient - Includes initial physical assessment & patient history - Need accurate documentation of data gathered

What Information is Confidential?

- All information about the patient - Name - Age - Date of birth - Any demographics - Diagnosis - Treatment - Anything written or spoken

Health Information Exchange (HIE)

- Allows various healthcare providers and patients to appropriately access & securely share a patient's vital medical information electronically - Improves speed, quality, safety, & cost of patient care - One benefit: stimulates consumer education & patients' involvement in their own healthcare

Privacy & Confidentiality

- Any information that a patient relates will not be made public or available to others without that patient's consent - Keeping information confidential protects the patient's right to privacy - The American Nurses Association's Code of Ethics states that nurses safeguard their patients' right to privacy by judiciously protecting confidential information

Focus Charting

- Brings focus of charting back to patient & patient's concerns - Focus is usually patient strength, need, or problem - DAR format—Data, Action, Response - What is patient issue? - What action or intervention was performed? - What was patient's response to action? - Principle advantage: holistic emphasis on patient & patient's priorities

Nursing Documentation - Care Plan

- Built around nursing process - Nurse communicates patient problems or diagnoses, outcomes, interventions, & patient progress - Standardized care plans - Issue of these standardized plans being individualized & not just checklist

Legal Documentation

- Can be used in courts of law as evidence - Can involve malpractice - Can involve accident & injury cases - Can be used in custody cases

Hand-off Communication--

- Change of shift report—nurse "hands off" the patient to the nurse caring for that patient on the next shift - Can be in various formats - Bedside reporting becoming more common - Basic identifying information - Current patient status—labs, testing findings, assessment findings - Current orders - Abnormal occurrences - Any patient/family questions concerns

Purposes of Patient Records

- Communication - Diagnostic & therapeutic orders - Care planning - Quality process & performance improvement - Research - Decision analysis - Education - Credentialing, regulation, & legislation - Legal documentation - Reimbursement

Charting By Exception - Disadvantage

- Difficult often to prove high quality - safe care was given

So Remember:

- Do not discuss patient information in public areas such as elevators, hallways, cafeteria, or home - Discuss patient information in pre and post clinical conferences - behind closed doors - Do not make copies of patient's medical records - Destroy patient documents before trashing - Do not remove medical records from patient care areas

Documenting Care

- Documentation - Patient record - Facility policies

Nursing Documentation - Medication administration record (MAR)

- Documentation of all medications administered to patient, which nurse administered, possibly reason for the medication, & patient's response to the medication - Often electronic

Case Management Model

- Emphasis on quality, cost-effective care given within a time frame using interdisciplinary documentation tool - Focus on outcomes that should be achieved on each day of care - Usually based on certain diagnoses - Work best for "typical" patients who don't have multiple problems and have few individualized needs - May use collaborative pathways and/or occurrence charting

Reports of Patient Care

- Face-to-face - Telephone - Written message - Audiotaped message - Computer message

Care Planning

- Gives all healthcare team members access to the patient's baseline & data from day to day so all can be aware of patient's progress toward outcomes

HIPAA

- Health Insurance Portability and Accountability Act of 1996 - Standards protecting confidentiality , integrity, & availability of data as well as standards defining when & where disclosures of patient identifiable health information are appropriate - More information available in ATI skills module

What is HIPAA?

- Health information - Any information, verbal or written, created or received by a healthcare provider related to past, present, or future physical or mental health or condition of an individual - Protected health information (PHI) - Individually identifiable health information

Benefits of EHRs

- Improve quality & convenience of patient care - Increase patient participation in their care - Improve accuracy of diagnoses & health outcomes - Improve care coordination - Increase practice efficiencies & cost savings in order to provide health care that is patient-centered, evidence-based, prevention-oriented, efficient, & equitable - Provide service elements, such as admission & discharge dates and expected payer for service

Research

- Information obtained from records used in studies to identify trends, to compare and contrast those with similar diagnoses, etc. - Promotes evidence-based practice in nursing and quality health care

Also Remember

- Keep discussions of patients and families professional - Never enter a patient record unless required - Never view own, family's or friend's medical record in clinical setting - If you are given a computer password, never share it - Log off before leaving a computer terminal

Telephone/Telemedicine Reports

- Link healthcare professionals immediately & allow nurses to give & receive critical patient information in timely manner - Nurse needs to be sure to: - Identify self & patient and state relationship to the patient - Report concisely & accurately the change in the patient's condition that is of concern and what has already been done in response to this condition - Report the patient's current vital signs and clinical manifestations - Have patient's record at hand to make knowledgeable responses to any provider's inquiries - Concisely record time and date of the call, what was communicated, and provider response

Hand-off Communication

- One of the Joint Commission's National Patient Safety goals - ISBAR communication - Identify/introduction - Situation - Background - Assessment - Recommendation

Abbreviations in Documentation

- Only use abbreviations in documentation that are approved by your institution - Use should be minimal

Problem-Oriented Records

- Paper record - Organized around patient's problems rather than around sources of information or disciplines - All disciplines record patient information on same forms - Team works closely together - Master list of patient problems involving all disciplines caring for patient - SOAP format (Subjective data, Objective data, Assessment, Plan)

Guidelines for Effective Documentation

- Patient record is only permanent legal document that thoroughly covers nurse's interactions with patient & is nurse's best legal defense - Content - Timing - Format - Accountability - Confidentiality

Communication

- Patient record is primary way for all disciplines involved in a patient's care to communicate about that care - Provides for continuity of care

Nursing care rounds

- Proactive, nurse-driven, evidence-based interventions that assist nurses in anticipating & addressing patient needs - Most effective if done hourly - Use Opening Key Words (C-I-CARE) with PRESENCE - Accomplish scheduled tasks. - Address four Ps (pain, personal needs, positioning, fall prevention - Address additional personal needs, questions - Conduct environmental assessment - Ask "Is there anything else I can do for you? I have time." - Tell the patient when expect to return - Document the round

PIE Charting

- Problem, intervention, evaluation - No separate plan of care; plan included in progress notes - Problems identified by numbers - Problems, their interventions, & an evaluation documented each shift - Resolved problems no longer included in daily progress notes

Nursing Documentation - Discharge & transfer summary

- Provides information on patient when transfers to another unit or is discharged to another level of care - Also includes instructions given to patient & family

Permitted Disclosure of PHI

- Public health activities - Law enforcement & judicial proceedings - Deceased people - Patient health Information (PHI) must not be improperly disclosed - Make sure those passing by don't see PHI - Say no to unauthorized requests for PHI

Nursing Documentation - Acuity records

- Ranking of patient acuity—measures severity of patient needs based on patient condition - Often used to determine staffing levels

Patients have the Right to

- See and copy their health record - Update their health record - Get a list of disclosures - Request a restriction on certain uses or disclosures - Choose how to receive health information

Charting By Exception

- Shorthand documentation - Uses well-defined standards of practice - Only significant findings or "exceptions" to the standards are documented in narrative notes •Disadvantage: Difficult often to prove high quality, safe care was given

Types of Personal Health Records (PHRs)

- Standalone personal health records: Patients fill in information from their own records; the information is stored on patients' computers or the Internet. - Tethered/connected personal health records: Linked to a specific health care organization's electronic health record (EHR) system or to a health plan's information system.

Source-Oriented Records

- Still often used in rural & underserved areas - Traditional paper records in which each healthcare discipline keeps data on their own separate forms - Usually have their own sets of progress notes—narrative notes - Progress notes usually include patient problem, its status, interventions, patient response, & any revisions needed - Documentation in reverse chronological order - Main disadvantage—information fragmented—can't really get a day to day picture of patient

Reimbursement

- Used by payers (insurance companies) to decide about payment - Are treatments medically necessary? - Did patients receive the treatment indicated?

Electronic Health Records (EHRs)

- Used to enter data - Used to pull up information - Used to enter plan of care - Used to enter patient progress toward outcomes - Can be used at patient bedside - Easy to compare information among various documentation of various disciplines - Contribute to research, education, and better, more efficient nursing practice

Diagnostic & Therapeutic Orders

- Vast majority of orders should be written by ordering physician or nurse practitioner - If nurse is unsure of what has been ordered, should always question - Only time nurse should take verbal order is in medical emergency when physician or nurse practitioner is unable to write it - Verbal order should be given directly to the nurse, not through a third party - Concept of "read back" - also good is the repeat back to make sure the patient understands what is going, what they are taking, and what they need to do

Documenting Care - Communication

- Wasn't written; Wasn't done - used for finance and legal records - helps with research

Nursing Documentation - Progress Note

- Way of documenting patient's daily progress on identified outcomes - May be any of the methods discussed earlier—often institution specific

Nursing Documentation - Flow Sheets & Graphic Records

- Way of documenting routine features of patient care - Graphic record: often used for specific patient variables such as pulse, temperature, blood pressure, intake & output, bowel movements

Delegating Documentation

- What documentation can be delegated to unlicensed personnel - Professional nurse often supervise these personnel - RN patient assessments and RN interventions should be charted by RN - Follow the facility's policies and procedures

Electronic Health Records (EHRs) - Safeguards

- bottom of page 466 & top of 467

Guidelines

- know aims (leave facts not "good" or "some" because that can be different for everyone - Document as soon as it HAPPENS! NEVER before it is DONE! - NEVER skip line in the reports! - people can write things in between. - Sign name, no scribbling out, cross through with 1 line and initial at mistake

Charting By Exception - Benefits

- less time spent documenting - greater emphasis on significant data - greater interdisciplinary communication - better tracking of important patient responses

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest? a- charting by exception b- Narrative notes c- FOCUS data, action, and response note d- Problem, intervention, and evaluation note

a- charting by exception

A nursing student is preparing a presentation on client records and documentation. What information should the student include in the presentation? a- communication is the primary purpose of client records b- nurses should not document progress notes in a client's record c- clients should keep the original record at home in a fire proof safe d- physicians will not review nurse's documentation in the client's record

a- communication is the primary purpose of client records

The nurse mistakenly documented one client's assessment data on another client's health care record. What action should the nurse take? a- draw a single line through the error, initial it, and write the correct entry b- use a dark-colored felt-tip pen to black out the error c- use correction fluid to cover the error and write the correct entry over it d- replace the record sheet and write the correct entry on the new sheet

a- draw a single line through the error, initial it, and write the correct entry

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to abbulate to the washroom. After assessing the client and assisting into the bed, the nurse has ompleted an incident report. What is the primary purpose of this particular type of documaentation? a- identifying risks and ensuring future safety for clients b- gauging the nurse's professional performance over time c- protecting the nurse and the hospital from litigation d- following up the incident with other members of the care team

a- identifying risks and ensuring future safety for clients

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes a- limiting abbreviations to those approved for use by the institution b- ensuring that abbreviations are understandable to clients who may seek access to their health records c- using only abbreviations whose meaning is self evident to an educated health professional d- using only those abbr that are defined in full at another location in the client's charts

a- limiting abbreviations to those approved for use by the institution

Which example may illustrate a breach of confidentiality and security of client information? a- the nurse provides information over the phone to the client's family member who lives in a neighboring state b- the nurse provides information to a professional caregiver involved in the care of the client c- the nurse accesses client information on the computer at the nurse's station, then logs off before answering a client's call bell d- the nurse informs a colleague that she should not be discussing client information in the hospital cafeteria

a- the nurse provides information over the phone to the client's family member who lives in a neighboring state CAN NOT give information to anyone without knowing the patient wants them to have it

Which clinical situation is addressed by the provisions of HIPPA? a- a client who resides in Indiana has required hospitalization during a vacation is Hawaii b- a client has asked a nurse if he can read the documentation that his physician wrote in his chart c- a client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test d- a client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer

b- a client has asked a nurse if he can read the documentation that his physician wrote in his chart

It is acceptable for the nurse to accept a verbal order from the physician in which situation? a- immediately prior to discharge b- during a medical emergency c- upon admission of the client to the unit d- prior to the client leaving the floor for therapy

b- during a medical emergency verbal is exceptable in an emergency any other time an order is needed

A nurse is documenting the effectiveness of a client's pain management on the client record. Which documentation is written correctly? a- Mr. Gray appears to have a low tolerance for pain and frequently reports intense pain. b- Mr. Gray is receiving sufficient relief from pain medication c- Mr. Gray reports that on a scale of 0 to 10, the pain he is experiencing is a 3 d- Mr. Gray appears comfortable and is resting adequately

c- Mr. Gray reports that on a scale of 0 to 10, the pain he is experiencing is a 3

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital fr clients with the disease, and their families. Providing this information is an example of a- a consultation b- reporting c- a referral d- conferring

c- a referral referring is the process of sending or guiding the client to another source for assistance. consultation is inviting another professional to evaluate the client and make recommendations. Conferring is exchange ideas + seek info, advice, or instruction. Reporting is communicating client data to others in any form.

Besides using the health care records, which form of communication should the nurse use to provide client details to the health care team coming on duty in the next shift? a- team conferences b- telephone calls c- change of shift d- client assignments

c- change of shift

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which information would the nurse expect to include when preparing the verbal handoff report? a- client's admission number b- client's family members c- current client assessment d- client's intake for previous meal

c- current client assessment

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting? a- record all facts and subjective interpretations b- use abbreviations wherever possible c- ensure that the client's name appears on all pages d- leave spaces between entries and signature.

c- ensure that the client's name appears on all pages. Ensures legally defensible charting.

which flow sheet provides the health care provider with information on an ongoing record of fluid loss? a- critical care flow sheet b- health assessment flow sheet c- intake and output graphic sheet d- vital signs graphic sheet

c- intake and output graphic sheet

A health care provider suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. What is the probable reason for this suggestion? a- the client needs to check the entry as well b- there are limited computer modules available c- it keeps the nurse close to the source of the data d- it solves the space constraint in the hospital

c- it keeps the nurse close to the source of the data

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records? a- any family member of the client b- health care professionals of the facility c- those directly involved in the client's care d- close friends of the client

c- those directly involved in the client's care

A nurse has administered 1 unit of glucose to the clilent as per order. What is the correct documentation of this information? a- 1U of glucose b- One U of glucose c- 1 bottle of glucose d- 1 Unit of glucose

d- 1 Unit of glucose

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details? a- narrative charting b- PIE charting c- FOCUS charting d- SOAP charting

d- SOAP charting

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? a- PIE charting b- Narrative charting c- FOCUS charting d- SOAP charting

d- SOAP charting

A hospital is changing the format for documentation in the attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note, in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting? a- variance charting b- FOCUS charting c- problem, intervention, evaluation (PIE) charting d- charting by exception (CBE)

d- charting by exception (CBE) CBE is shorthand documentation method that makes use of well-defined standards of practice.

The health care provider approches the nurse caring for the client in room 25 and states, "The client is a friend of mine. What treatment is being given?" What response by the nurse is most appropriate? a- tell the health care provider to contact the provider caring for the client to obtain any information b- inform the health care provider of a busy schedule preventing answering any questions c- open the health care record for the doctor to review d- inform the health care provider that client permission is needed to release any information

d- inform the health care provider that client permission is needed to release any information

When taking a telephone order from a physician, the nurse verifies that they understand the order by a- faxing the written order to the physician's office b- confirming the order with the nurse manager c- asking the physician to summarize the orders given d- repeating the order back to the physician

d- repeating the order back to the physician the repeat back technique it a great way to make sure you can read and/or under exactly what is needed

When documenting information in a client's health care record, what should the nurse do consistently for each entry? a- report each observation to the physician b- obtain a signature from the physician c- provide the day of the week on the entry d- sign each entry by name and title

d- sign each entry by name and title

A new graduate is working at a first job. Which statement is most important for the new nurse to follow? a- only document changes in the client's status b- use PIE charting even if it is not the institution's charting method c- Document lengthy entries using complete sentences d- use abbreviations approved by the facility

d- use abbreviations approved by the facility

The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which clinical situation? a- when reporting to a client's family member or significant other b- when documenting the care that was provided to a client whose condition recently deteriorated c- when preparing to discharge the client home d- when transferring a client from the emergency department to the acute care unit

d- when transferring a client from the emergency department to the acute care unit

Hand-off Communication -

•Be professional •Keep report focused on patient •Gather all pertinent data before communicating •No derogatory remarks