Chapter 17

A HIPPA violation can bring punishment of up to...

$25,000 in fines and 10 years in prison

There are 3 exceptions to the authorization provision under HIPPA. What are they?

- *public health activities* (track outbreaks, i/d control, etc) - *law enforcement*/judicial procedures - *deceased individuals* (info needed for organ donation, funeral directors, coroners, etc)

Important instances when a progress note should be written. (4)

- admission, transfer, discharge - when a procedure is performed - when receiving a pt post-op or post-procedurally - with any change in status

What information is typically shared in a change-of-shift report?

- basic id-ing info abt the pt - current appraisal of the pt's health status --incl any changes in status during your shift, pt response, Tx given --pertinent monitoring, lab, radiology data, esp anything irregular or that's now been resolved --abnormal findings in your head/toe assessment --where pt stands in rel to n. dx and goals -Current orders (esp new or changed orders) -Abnormal occurances -Unfilled orders that need to be continued -Transfers/discharges

What are examples of documentation that increases risk for legal problems?

- content is not in accordance w/ professional or organizational standards - content doesn't reflect patient needs - content is incomplete/inconsistent - content doesn't include appropriate medical orders - content implies a potential risk not acted upon - content implies discrimination or attitudinal bias

Regarding documentation, each nurse is expected to practice according to what? (2)

- local policies - professional standards

What purposes to patient records serve? (10)

- record of diagnostic & therapeutic orders - care planning - decision analysis - communication w/ other HCP - legal record - reimbursement - research - quality of care review (Q/A) - education - historical documentation

According to HIPPA a client has the right to...(5)

- see and copy their health record - update their health recrod - get a list of disclosures made, independent of payment, treatment, and h/c operations - request restriction on certain disclosures - choose the method of communication of h/c information

HIPPA allows for the release of PHI w/ out an authorization for which 3 purposes?

- treatment - payment - routine health care operations

Chart nursing interventions chronologically and on...

...consecutive lines. Never skip a line. Cross out blank spaces with a single line.

The nursing minimum data set is organized into what 3 categories?

1. Nursing care elements (dx, interventions, etc) 2. Patient demographic elements (sex, dob, ethnicity) 3. Service elements (ie. admission & discharge dates, expected payer info, etc.)

What are the steps in receiving verbal orders?

1. Record the orders in the pt's medical record 2. Read back the order to verify accuracy. 3. Date & note the time the orders were issued. 4. Record V.O. (verbal orders), name of provider, followed by RN's name and title.

What are examples of permitted incidental disclosures? (7)

1. Sign-in sheets 2. Conf. convo overheard (in protected environment) 3. Placing charts outside exam rooms 4. Use of white boards 5. X-ray light boards seen by passes-by 6. Calling out names in the waiting room 7. Leaving appt reminder vm's

Patient Record

A compilation of a patient's health information.

Who can give/receive verbal orders and in what scenario?

A physician or NP can give verbal orders in an emergency setting. An RN or Pharmacists can receive these orders.

How does documentation support care planning?

A record shows daily progress and response to treatments and interventions, and supports planning.

Incidental Disclosure of PHI is defined as:

A secondary disclosure that cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of PHI.

What information is confidential?

All information about a patient - whether written on paper, saved in a computer, or spoken aloud - is confidential and private.

DAR of Focus Charting

Data, Action, Response

What two notes should you make regarding time in a patient record?

Date/time of documentation Date/time of observation

What would be included in a nurse's narrative notes?

Descriptions of *pertinent observations*.

What form is used to chart specific pt variables, like BP, T,P,R?

Graphic sheets

What's the primary purpose of an incident report?

Identifying risks for the goal of quality improvement.

Charting by Exception (CBE)

Makes use of well-defined standards of practice, charting only significant findings or exceptions. Limited usefulness in some regards due to lack of information documented.

What is a key component to facilitating data and outcome comparisons by using uniform definitions to create a common language among multiple healthcare data users?

Minimum data sets

Which is more important to document, observations or interpretations?

Observations only! Use specifics - numbers, scales, descriptive terms that communicate exact circumstances.

Source-oriented data

One in which sheets are *organized by group* - nursing, radiology, laboratory personnel, etc.

PHR

Personal Health Records - tools many individuals are using to compile personal health data online for easier personal management.

POMR

Problem Oriented Medical Record - by Dr. Lawrence Weed in 1960s HCT uses the same form to generate a full list of patient problems & contributions to collaboratively plan care.

PIE Charting

Problem, Intervention, Evaluation - promotes continuity of care

In what system is the SOAP format used?

Problem-oriented method

Narrative notes

Progress notes written by nurses in a oriented format

What does the nurse document in a 24-hour nursing care record?

Routine aspects of care that promote goal achievement, safety, well being.

What does a flow sheet record?

Routine care: Think Gordon's + Progress sheet

What format is used to organize info in a POMR?

SOAP - subjective, objective, assessment, plan

Documentation

The written or typed legal record of all relevant interactions with a patient - including assessing, diagnosing, planning, implementing, and evaluating.

What's the purpose of Focus Charting?

To bring the *focus of care back to the patient* and the patient's concerns. (v. problem list or list of med dx)

Collaborative Pathways

Used in the *case management model* - specify the plan of care linked to expected outcomes along a timeline.

Variance Charting

Used to document the unexpected event, the cause, actions taken, and discharge planning (when appropriate).

Information in a pt record should be...(7)

complete accurate factual concise current organized entered in a timely manner

A graphic sheet is used to record

specific pt variables such as TPR, BP, etc

What is the best and only defense in the face of negligence charges?

the patient record