ch 19 documenting and reporting

patients don't have the right to

*revise* health record

What is confidentiality?

All information about patient written on paper, spoken aloud, saved on computer ex. name, address, phone, fax, ssn research the person is sick treatment pt receives information about past health conditions

Purposes of Patient Records

Communication Diagnostic and therapeutic orders Care planning Quality process and performance improvement Research; decision analysis Education Credentialing, regulation, and legislation Reimbursement Legal and historical documentation

Medicare Requirements for Home Health Care

Patient is homebound and still needs skilled nursing care. Rehabilitation potential is good (or patient is dying; hospice). The patient's status is not stabilized. The patient is making progress in expected outcomes of care.(may not be completely healthy but can be better)

Standalone personal health records

Patients fill in information from their own records; the information is stored on patients' computers or the Internet. (ex. putting in castle branch)

Methods of Documentation

Source-oriented records Problem-oriented medical records PIE charting (problem, intervention, evaluation) Focus charting Charting by exception Case management model Computerized documentation/Electronic health records (EHRs)

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? a.Notifying the nursing team of the client's condition b.Accurately documenting client care on the client record

b. The client record is the only permanent legal document that details the nurse's interactions with the client and is the nurse's best defense if a client or client surrogate alleges nursing negligence.

computerized documentation is used to

call up admission data develop the care plan add to the patient database receive a work list document care immediately

The PIE (Problem, Intervention, and Evaluation)

charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). This would not be the best method of documentation if the nurse wanted the documentation to stand out regarding the client's condition.

Elements of Documentation

content(cannot be your own opinion and concise), timing, format, accountability, confidentiality

major components of problem oriented medical record

defined database problem list (ex. pt says they feel hot and temp is at 100.3 F) care plans (give them Tylenol evaluate in 30 min) progress notes SOAP format

The plan of care

identifies methods for solving each identified health problem.

SOAP notes (Subjective data, Objective data, Assessment, Plan)

is used to organize entries in the progress notes, focusing primarily on the client and any identified problems.

charting benefits

less time needed for charting greater emphasis on significant data easy retrieval of significant data timely bedside charting standardized assessment greater interdisciplinary communication better tracking of patient responses lower cost limited usefulness when trying to prove that high quality safe care was given

Four Basic Components of RAI (Resident Assessment Tool)

minimum data set (further evaluation) triggers resident assessment protocols (use medicare/medicade to evaluate pt) utilization guidlines (use resident assessment tools)

case management model

promotes collaboration, communication, and teamwork among caregivers; makes efficient use of time; and increases quality by focusing care on carefully developed outcomes.

what is only written in narrative notes

significant findings

benefits of a health information exchange

- provides a vehicle for improving quality and safety of patient care - provides a basic level of interoperability among EHRs maintained by individual physicians and organizations (doctors and hospital info together) - stimulates consumer education and patients' involvement in their own health care - helps public health officials meet their commitment to the community - creates a potential loop for feedback between health-related research and actual practice - facilitates efficient deployment of emerging technology and health care services - provides the backbone of technical infrastructure for leverage by national and state-level initiatives

Change of Shift/Hand-off Reports

-Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians -Current appraisal of each patient's health status -Current orders (especially any newly changed orders)(always double check) -Abnormal occurrences during your shift -Any unfilled orders that need to be continued onto the next shift -Patient/family questions, concerns, needs -Reports on transfers/discharges

Telephone/Telemedicine Reports

-Identify yourself and the patient, and state your relationship to the patient. -Report concisely and 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 the patient's record at hand to make knowledgeable responses to any physician's inquiries. -Concisely record time and date of the call, what was communicated, and physician's response.

HIPAA allows incidental disclosures of client health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of client health information. What are examples of this type of client health information disclosure? Select all that apply. 1.A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. 2.The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. 3. The nurse calls out names in the waiting room, but does not disclose the reason for the client visit.

1, 2, 3,

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. 1.Fever, possible urinary tract infection 2."I don't feel well. I've been urinating often and it burns when I urinate." 3.Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. 4. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. 5."I don't feel well. I've been urinating often and it burns when I urinate." 6. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago.

1,4,5, 6

characteristics of effective documentation

Consistent with professional and agency standards (terminology) Complete Accurate Concise Factual Organized and timely (chart in a timely manner) Legally prudent (documenting the pt state "blah blah...") Confidential (sign off of the computer)

conferring about care

Consultations and referrals Nursing and interdisciplinary team care purposeful rounding Nursing care rounds

Potential Breaches in Patient Confidentiality

Displaying information on a public screen Sending confidential e-mail messages via public networks Sharing printers among units with differing functions Discarding copies of patient information in trash cans (shread) Holding conversations that can be overheard Faxing confidential information to unauthorized persons Sending confidential messages overheard on pagers

Types of Flow Sheets

Graphic record 24-hour fluid balance record (I&O) Medication record 24-hour patient care records and acuity charting forms(how sick the pt are or looking at how much staffing we need)

ISBARR

Identity/Introduction "Hi my name is...." Situation Background Assessment(need assistance with...) Recommendation Read back of orders/response

Formats for Nursing Documentation

Initial nursing assessment Care plan; patient care summary Critical collaborative pathways Progress notes Flow sheets and graphic records Medication record Acuity record Discharge and transfer summary Long-term care documentation

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. (way to see your health record)

which method of documentation is unique in that it does not develop a separate care plan but instead incorporates the care plan into progress notes

PIE (PROBLEM, INTERVENTIONS, EVALUATIONS)

Policy for Receiving Verbal Orders in an Emergency

Record the orders in patient's medical record. Read back the order to verify accuracy. Date and note the time orders were issued in emergency. Record verbal order and name of the physician issuing the order, followed by nurse's name and initials.

Duties of RN Receiving Telephone Orders

Record the orders in patient's medical record. Read orders back to practitioner to verify accuracy. Date and note the time orders were issued. Record telephone orders, and full name and title of physician or nurse practitioner who issued orders. Sign the orders with name and title.

benefits of RAI

Residents respond to individualized care. Staff communication becomes more effective. Resident and family involvement increases. Documentation becomes clearer.

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan? a.progress notes b.data base

a

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? a."A coronary artery bypass graft will benefit your heart." b."The CABG procedure will help identify nutritional needs."

a Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.

A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format? a.Charting by exception b.PIE

a.is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in CBE narrative-style notes. The question is asking about a pregnant woman with hypertension. This is not an expected situation for a typical pregnant woman, so CBE is a way to document this situation so that it will be immediately seen in the documentation.

Narrative notes

address routine care, normal findings (findings that do not call for changes in the plan of care), and client problems identified in the plan of care

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response? a. "HIPAA legislation only allows access to review the medical record." b.According to HIPAA legislation, you have a right to request changes to inaccurate information."

b

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? a. "It will let me see everything that has been done and things that need to be done." b."It will allow for us to see the client and possibly increase client participation in care."

b

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes in to the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? a.Report error to primary provider. b.Attach a copy of the incident report to the chart.

b

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? a.Asking the emergency department nurse for information on the family member b. calling the client information desk to find out the room number of the family member

b

Which documentation tool will the nurse use to record the client's vital signs every 4 hours? a. acuity charting forms b. a flow sheet

b. is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics.

purpose of recording data

facilitate quality, evidence based patient care help in clinical research support decision analysis serve as a financial and legal record

Acuity charting

forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention.

the data base contains

initial health information about the client.

the problem list contains

of a numeric list of the client's health problems

Patients have the right to what?

see and copy their health record update the health record get a list of disclosures request restriction on certain uses or disclosures (ex. if someone has HIV it may not be displayed everywhere) choose how to receive health information

eight behaviors of purposeful rounding

use opening key words with presence accomplish scheduled address additional personal needs and questions conduct environmental assessment ask if there anything else I can do for you I have time tell the patient when you will be back document the round

Incident, Variance, or Occurrence Reports

used by facility to document anything out of the ordinary that result in or has potential to result in an injury to patient, visitor, or employee intended as quality assurance reports not disciplinary reports to identify risks, including potential legal risks

Reports to Family Members and Significant Others

you must have consent of the patient to give report identify who may have information and whom may not if using a code give the person to receive information the code and document what it is in the appropriate place