informatics and documentation

forms of record keeping

-Admission nursing history form: -Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems -Flow sheets and graphic records: -Help team members quickly see patient trends over time and decrease time spent on writing narrative notes -Patient care summary or Kardex: -Computerized systems provide certain basic information in the form of a patient care summary -A Kardex is a portable "flip-over" file or notebook with patient information notes: The patient chart includes a variety of forms to make documentation easy, quick, and comprehensive. When possible, avoid duplication within the record. Admission nursing history forms provide baseline data for later comparisons with changes in the patient's condition. Flow sheets allow you to quickly and easily enter assessment data about a patient. They use a coding system for data entry. Many hospitals now have computerized systems that provide information in the form of a patient care summary that is often printed for each patient during each shift. The summary automatically updates as nurses make decisions, and data (e.g., orders) are entered into the computer. In some settings, a Kardex is kept at the nurses' station. An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day.

health informatics

-Application of computer and information science for managing health-related data -Focus on the patient and the process of care -Goal is to enhance the quality and efficiency of care provided. -Informatics is the study of the retrieval, storage, presentation, and sharing of data, information, and knowledge to provide high-quality, safe patient care. -A health care information system (HIS) is a group of systems used in a health care organization to support and enhance health care.

Interdisciplinary Communication Within the Health Care Team

-Interdisciplinary communication is essential within the health care team. -Records or chart: Confidential permanent legal document -Reports: Oral, written, or audiotaped exchange of information The typical patient has many caregivers, including nurses, physicians, nursing assistive personnel, and therapists. To maintain high-quality care, it is essential that effective communication occur among all health team members. Purpose of medical records = helps to ensure that all health team members are working toward a common goal of providing safe and effective care. Patients' records' and reports are two means for effective communication. A patient's record or chart is a confidential, permanent legal documentation of information relevant to that patient's health care. Information about the patient's health care is recorded after each patient contact. Records can be either paper or digital, depending upon the system used by the health care agency. Reports are oral, written, or audiotaped exchanges of information between members of the health care team. Common reports given by nurses include change-of-shift reports, telephone reports, transfer reports, incident reports, and hand-off reports. The original record is the property of the healthcare agency. However, patient's may request and get a copy of their medical records.

progress notes

-Narrative: the traditional method -SOAP: Subjective, objective, assessment, plan -SOAPIE:Subjective, objective, assessment, plan, intervention, evaluation -PIE:problem, Intervention, evaluation -Focus charting (DAR): Data, action, response ​Health care team members use progress notes to monitor and record the progress of a patient's problems. Narrative notes, flow sheets, discharge summaries, and structured notes are formats you use to document the patient's progress. Narrative documentation uses a story like format. Weaknesses of the narrative format include repetition, length, and disorganization. The intent of SOAP, SOAPIE, PIE, or DAR charting formats is to organize entries in the progress notes according to the nursing process.

confidentiality

-Nurses are legally and ethically obligated to keep all patient information confidential. -Nurses are responsible for protecting records from all unauthorized readers. -HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary. All information pertaining to a patient's health care management is confidential. Legislation to protect patient privacy for health information, the Health Insurance Portability and Accountability Act (HIPAA), governs all areas of health information management, including reimbursement, medical record coding, security, and patient record management. Access to patient records is limited to individuals involved in the care of the patient. You can review your patients' medical records only for information needed to provide safe and effective patient care. Nurses may not disclose information about a patient's status to other patients, family members (unless granted by the patient), or to health care staff not involved in their care. Patients, of course, have the right to read their own records. Students must be very aware of how they collect and transport patient data. Make sure written materials used in your student clinical practice do not include patient identifiers, such as room number, date of birth, medical record number, or other identifiable demographic information. Do not share patient information with your classmates. Students are bound by the same confidentiality laws as other health care providers.

mandated reporting

-Nurses are mandated reporters -Required to report any situation in which an injury is present and appears to be the result of abuse, neglect, or exploitation. -Of special note: children and the elderly -Notify Social Services notes: It is mandatory for health care providers to report incidents such as child, spousal, or elder abuse; rape, gunshot wounds; attempted suicide; and certain communicable diseases. To encourage reports of suspected cases, states provide legal immunity for the report if the person makes the report in good faith. Health care professionals who do not report suspected child abuse or neglect are liable for civil or criminal legal action. You are also required to report unsafe or impaired professionals.

hand off reporting

-Occurs with transfer of patient care -Provides continuity and individualized care -Reports are quick and efficient. -Examples include change-of-shift reports and transfer reports notes; A handoff is the process of transferring responsibility for patient care from one provider to another. For example, if you find that a patient breathes better in a certain position, you relay that information to the next nurse caring for the patient. Hand-off reports can be paper, voice recordings, or electronic. Examples of hand-off reports include change-of-shift reports and transfer reports. The change-of-shift report is one type of hand-off report that occurs at the end of each shift. This report provides the transfer of relevant information from nurses who have completed a shift of care to nurses about to begin a shift of care. A transfer report is another type of hand-off report that involves communication of information about patients from the nurse on the sending unit to the nurse on the receiving unit. Transfer reports are usually completed by phone or in person.

patient record information

-Patient identification and demographic data -Informed consent for treatment or procedures -Admission data -Nursing diagnoses or problems and nursing or interdisciplinary care plan -Record of nursing care treatment and evaluation -Medical history and physical examination -Medical diagnoses -Therapeutic orders -Medical and other health discipline progress notes -Results of diagnostic and therapeutic tests and procedures -Patient education -Advance directives -Summary of operative procedures -Discharge diagnosis, plan, and summary

nursing information systems

-Privacy, confidentiality, and security mechanisms -Handling and disposal of information -Destroy anything that is printed when the information is no longer needed. -Know the disposal policies for records in the institution where you work.

forms of record keeping

-Standardized care plans: -Preprinted, established guidelines used to care for patients who have similar health problems -Discharge summary forms: -Reinforces explanations with printed instructions -Reviews signs and symptoms that should be reported to primary care provider -Contains follow up plans notes: -Some institutions use standardized care plans to make documentation more efficient. After completing a nursing assessment, the nurse identifies the standard care plans that are appropriate for the patient and places the plans in the patient's medical record. -The primary goal of a discharge summary is to ensure the continuity of care, whether a patient is going home or transferring to another institution. A nursing discharge note needs to cover the reason for hospitalization, procedures performed, care, treatment, and services provided, patient's status at discharge, information provided to the patient and family, and provisions for follow-up care.

documentation

-Written and/or printed material in a patient record -Legal record of care -Permanent document, admissible in court -Reflects care provided -Provides accountability -Provides evidence for credentialing, research, reimbursement and is a care planning database. TJC (The Joint Commission) and CMS (Centers for Medicare and Medicaid services) require health care institutions to monitor and evaluate the quality and appropriateness of patient care. As of 10/1/2008, Medicare no longer reimburses hospitals for preventable conditions such as hospital acquired illnesses and injuries ( for example, catheter acquired infection and pressure ulcers) Documentation must accurately reflect the patient at admission, transfer and discharge.

tasks that can not be delegated

Assessment Interpretation of data Making a nursing diagnosis Creation of a nursing care plan Evaluation of care effectiveness Care of invasive lines Client education

purpose of records

-communication -reimbursement -research -legal documentation -education -quality process and performance improvement *Main purpose is to make sure everyone is working towards the same goal* Remember that even if nursing care has been exemplary, "Care not documented is care not provided." A patient's record is a valuable source of data for all members of the health care team and the only permanent record documenting patient care from admission to discharge. Documentation serves multiple purposes, including communication, legal documentation, reimbursement, education, research, and quality process and performance improvement. -Communication: The record is a way for health care team members to provide continuity of care and to communicate patient needs and progress toward meeting desired patient outcomes. The record is the most current and accurate source of information about a patient's health care status. It is best to document immediately following an assessment or intervention. -Legal documentation: Because jurors usually rely on information documented in the medical record to determine the patient care provided, effective documentation is one of the best defenses for legal claims associated with health care. Record keeping is a professional responsibility and not an optional extra. Be sure to follow organizational standards. -Reimbursement: Charting also determines the amount of reimbursement a health care agency receives. Diagnosis-related groups (DRGs) have become the basis for establishing reimbursement for patient care. A medical record audit reviews patient care and at times determines reimbursement. -Education: Reading the patient care record is an effective way to learn the nature of an illness and the patient's response to the illness. Review of patients with similar medical problems allows you to identify patterns and trends. Such information builds your clinical knowledge. -Research: Research often determines changes made to nursing procedures and protocols. To improve quality of care, researchers collect and study statistical data from patient records. Analysis of data contributes to evidence based practice. -Quality process and performance improvement: The Joint Commission requires hospitals to establish quality improvement programs for conducting objective, ongoing reviews of all patient care. Quality processes and performance improvement measures provide a method to evaluate quality of care in order to ensure the achievement of legislative mandates or address quality initiatives.

Guidelines for Quality Documentation and Reporting

1. Complete: Contains care administered AND the patient's response Includes routine activities such as daily hygiene, vital signs, etc. 2. Current: Make entries promptly Vitals, medications, treatments Use military time 3. Organized: Logical, sequential order The information within a recorded entry or a report needs to be clear, concise, and complete, containing appropriate and essential information. Making entries promptly is essential in effective documentation. Delays in documentation result in serious omissions, untimely delays, and possible errors in patient care. Most health care agencies use military time, a 24-hour system that avoids misinterpretation of am and pm times. Written communication is easier to understand when written in a logical, sequential order.

legal guidelines for recording

1.Correct all errors promptly, using the correct method. 2.Record all facts; do not enter personal opinions. 3.Do not leave blank spaces in nurses' notes. 4.Write legibly in permanent blank ink. 5.If an order was questioned, record that clarification was sought. 6.Chart only for yourself, not for others. 7.Avoid generalizations. 8.Begin each entry with the date/time and end with your signature and title. 9.Keep your computer password secure.

C

A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of A. PIE documentation. B. SOAP documentation. C. Narrative charting. D. Charting by exception.

D

A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to A. Exchange information among health care members. B. Provide information about patients from one unit to another unit. C. Ensure proper care for the patient. D. Aid in the hospital's quality improvement program.

Principles of delegating to NAP

Assess the client Client must be medically stable or in a chronic condition and not fragile Task routine for this client Not require a substantial amount of scientific knowledge or technical skills Considered safe for this client Have a predictable outcome

elements of hand off report

Basic identifying information: Name, age, medical diagnosis Significant changes in condition: New physician orders Provide exact information regarding interventions for significant changes Client's need for emotional support notes: A sample format is as follows: Background information (name, age, medical diagnosis) Primary health problem Unusual occurrences Discharge planning issues Identification of significant changes in measurable terms (ex. Pain scale) Observations, findings, time when new stat or prn medications were given Care required When a dressing needs to be changed next Progress with teaching plan Emotional support needed Family involvement. It is especially important to report any recent changes or priority situations concerning the patient's condition. Do not include normal findings or routine information retrievable from others sources or derogatory or inappropriate comments about a patient or family.

informatics and documentation

Documentation is a key element of nursing practice and a key communication strategy between health care professionals. Documentation is anything written or printed within a patient record, which may be either paper, electronic, or a combination of both formats. The information communicated by nurses regarding their patients' care reflects the quality of care and accountability for care provided. Accreditation agencies such as The Joint Commission specify guidelines for documentation. Nurses need to follow basic principles to maintain confidentiality during the transmittal of patient information via verbal, written, or electronic media formats

Guidelines for safe computer charting:

Don't share your password Log off when unattended Follow policy in correcting errors Avoid leaving information where others can see it Protect any printed information

methods of documentation

Charting by exception(CBE): -focuses on documenting deviations Case management plan and critical pathways: -incorporaties a multidisciplinary approach to care -variances Charting by exception (CBE) reduces documentation time and highlights trends or changes. The assumption with this method is that all standards are met unless otherwise documented. The case management model of delivering care incorporates an interdisciplinary approach to documenting patient care. Critical pathways are interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established time frame. Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame are called variances.

standards

Current documentation standards require that each patient have an assessment: -Physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs Nursing documentation standards are set by federal and state regulations, state statutes, standards of care, and accreditation agencies. The medical record is a legal document that requires information describing the care that is delivered to a patient. Know the standards of your health care organization to ensure complete and accurate documentation. Your documentation needs to conform with standards of the National Committee for Quality Assurance (NCQA) and accrediting bodies such as The Joint Commission (TJC) to maintain institutional accreditation and minimize liability. TJC standards require that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning. Other standards, such as HIPAA, include those directed by state and federal regulatory agencies and are enforced through the Department of Justice and the Centers for Medicare and Medicaid Services (CMS).

delegation

Delegation is the transference of responsibility and authority for an activity to a competent individual Delegator retains accountability of the outcome Enhances skills and abilities of the delegate

nursing rounds

Discussion of client care held at the bedside with two or more nurses and the client Purpose: obtain information to help plan nursing care and evaluate care received Assigned nurse provides a summary of care and interventions Client contributes to the discussion

Guidelines for Quality Documentation and Reporting

Factual: -Objective data: A factual record contains descriptive, objective information about what you see, hear, feel, and smell. Avoid the words appears, seems and apparently. -Subjective data: The patient's statements are subjective data. When recording subjective data, document the patient's exact words within quotation marks whenever possible. For example, the patient states "I feel nervous." Another way to document is: Patient reports feeling pressure in chest. (pain is subjective) Accurate and concise: -The use of precise measurements makes documentation more accurate. For example, documenting "Voided 450 mL clear urine" is more accurate than "Voided an adequate amount." -Correct spelling demonstrates a level of competency and attention to detail. Misspelled words lead to confusion. -The information within a recorded entry or a report needs to be clear, concise, and complete, containing appropriate and essential information.

A

Information regarding a patient's health status may not be released to non-health care team members because A. Legal and ethical obligations require health care providers to keep information strictly confidential. B. Regulations require health care institutions to document evidence of physical and emotional well-being. C. Reimbursement issues related to patient care and procedures may be of concern. D. Fragmentation of nursing and medical care procedures may be identified.

5 rights of delegation

Right Task Right Circumstances Right Person Right Direction and Communication Right Supervision and Evaluation The nurse is responsible for all care given to the client.

telephone reports and orders

Situation-background-assessment-recommendation (SBAR) Document every call Read back

incidence or occurence report

Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient Follow agency policy

methods of documentation

paper records: -Episode oriented -Key information may be lost from one episode of care to the next. -Down time forms!!! Electronic Health Record (EHR): -A digital version of a patient's medical record -Integrates all of a patient's information in one record -Improves continuity of care Staff use the same documentation system throughout an agency. There are several acceptable methods for recording health care information. Traditionally health care professionals documented medical records on paper. Paper records are episode oriented, with a separate record for each patient visit to a health care agency. The need for patient safety has driven the increased use of computerized documentation systems. Hospitals and health care professionals are transitioning to use of electronic health records (EHR). The EHR integrates all pertinent patient information into one record, regardless of the number of times a patient enters a health care system. It ensures coordination of care because all primary caregivers can view a common record of a patient's entire health care experience, including inpatient, outpatient, and emergency care, as well as diagnostic studies. The EHR differs from the EMR (electronic medical record), although terms are used interchangeably. The EMR contains patient data gathered in a health care setting at a specific time and place and is part of the EHR. In 2010, the Patient Protection and Affordable Care Act (ACA) mandated that health care agencies purchase a computerized information system and demonstrate "meaningful use." Meaningful use refers to the level with which information technology is available and used to support clinical decision making to improve quality, safety, and efficiency; reduce health disparities; engage patients and families in their health care; improve care coordination; improve population and public health; and maintain privacy and security. These benchmarks require health care providers to report certain data related to performance improvement and patient outcomes.