NUR 102 Chapter 16 (Documenting, Reporting, Conferring, and Using Informatics) Key Terms

A client made a formal request to review their medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information." Explanation: The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records, and they can also obtain a copy of it. Therefore, clients reserve the right to request changes in accurate information. The other responses are inaccurate.

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is:

"I am sorry, but verbal orders can only be given in an emergency situation that prevent us from writing them out. I'll bring the chart and we can do this quickly." In most agencies, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician/ nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order.

According to HIPAA, patients have the right to:

*See and copy their health record *Update their health record *Get a list of disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations *Request a restriction on certain uses or disclosures *Choose how to receive health information

The benefits of EHRs at the bedside and else:

1. Improve quality and convenience of patient care 2. Increase patient participation in their care 3. Improve accuracy of diagnoses and health outcomes 4. Biggest one here - Improve care coordination

Hand-off

A nurse's report to another nurse or health care provider about a patient's status and progress

ISBARR Communication

A process for effective hand-off communication among health care professionals about a patient's condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back.

Incident/ Variance Report

A report of any event that is not consistent with the routine operation of the health care agency that results in or has the potential to result in harm to a patient, employee, or visitor

Variance Report

A report of any event that is not consistent with the routine operation of the health operation of the health care agency that results in or has the potential to result in harm to a patient, employee, or visitor

Minimum Data Set

A standard established by health care institutions that specifies the information that must be collected from every patient

Electronic Database

An electronic database is a collection of data that allows easy sharing and easy retrieval of similar pieces of data from many records.

The nurses at a healthcare facility were informed of the change to organize the clients' records into source-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Explanation: Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among healthcare providers is an advantage of problem-oriented recording and is therefore correct.

How can the nurse researcher obtain information from a client record?

Study client records. Explanation: Nursing and health care research is often carried out by studying client records.

Health care smart card

The health care smart card is similar to a credit card, with a magnetic strip that contains vital emergency health care information or creates a link to information in another location.

Patient Care Summary

The patient care summary contains an overview of valuable patient information such as documentation, lab and test results, orders, and medications.

Formats for Nursing Documentation

When the nursing process is fully implemented, nursing documentation in the patient's permanent record includes the following formats.

Which are principles of documentation? Select all that apply.

• Confidentiality • Accuracy • Objective • Timely Explanation: The principles of proper documentation include confidentiality, accuracy, completeness, concise, objective, organized, timely, and legibility.

Initial Nursing Assessment

A typical electronic form used to record the initial database obtained from the nursing history and physical assessment. Accurate documentation of these data is important to provide a baseline for later comparisons as the patient's condition changes

Health Information Exchange (HIE)

An "electronic system" that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient's vital medical information. Moreover, it is an organization as a matter of fact, that provides services to enable the electronic sharing of health-related information.

Electronic Medical Record (EMR)

An EMR is an electronic patient care record created by an agency or agencies having common ownership. The different between an EHR and an EMR is that EMR's are not shared between providers in agencies under different ownership.

A nurse administering medications accidentally gives a double dose of blood pressure medications. After ensuring the safety of the client, the nurse would document the error in which documents?

Client's record and occurrence report. Explanation: An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

Personal Health Record (PHR)

Information sheets that contain the individual's medical history, including diagnoses,symptoms, and medications. Many people today are preparing online personal health records (PHRs) to manage their health care via computer. These records contain the person's medical history, including diagnoses, symptoms, and medications. The chief reason for a Personal Health Record is to provide easy access to up-to-date, complete health information to assist in self-care, and communication with providers.

SOAP Format Used to organize entries in the progress notes of the POMR (Problem-Oriented Medical Records)

Method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P) = SOAP This SOAP Format is used to organize entries in the progress notes of the POMR. Caregivers select numbered problems from the master list on the front of the patient record and then work up the problem or "SOAP it" on the progress sheet. Some nurses believe that the SOAP method of charting focuses too narrowly on problems and advocate instead a return to the traditional narrative format. Variants of the SOAP format include SOAPE, SOAPIE, and SOAPIER (Intervention, Evaluation, and Response) * Progress notes focus on patient problems

SBAR

Situation, Background, Assessment, Reccommendations

Confer

To consult with someone to exchange ideas or to seek information, advice, or instructions.

A client was recently hospitalized. In order to process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy?

Use minimum disclosure policy to release the information. Explanation: The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment

Electronic Health Record (EHR)

a digital version of a patient's paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. The EHR is the patient care record created when agencies under different ownership share their data. The goal is for this sharing to be nationwide, creating a situation in which a person's health care is accessible by designated HEALTH CARE PROVIDERS anywhere in the nation. The patient will decide which portions of a record will be available to whom.

A nurse is using the SOAP format of documentation to document care of a patient who diagnosed with type 2. diabetes. Which source of information would be the nurse's focus when completing this documentation? a. A patient problem list b. Notes describing the patient's condition c. Overall trends in the patient status d. Planned interventions and patient outcomes

a. A patient problem list. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Abnormal status can be seen immediately when using charting by excepting, and planned interventions and patient expected outcomes are the focus of the case management model. Think: "SOAP IT"

According to the Health Insurance Portability and Accountability (HIPPAA) Act of 1996, if a health institution wants to release patients health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed? Select all that apply. a. News media are preparing a report on the condition of a public figure. b. Data are needed for the tracking and notification of disease outbreaks. c. Protected health information is needed by a coroner. d. Child abuse and neglect are suspected. e. Protected health information is needed to facilitate organ donation f. The sister of a patient with Alzheimer's wants to help provide care.

b, c, d, e. Authorization is not required for tracking disease outbreaks, providing PHI to a coroner, reporting incidents of child abuse, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease.

A nurse is documenting the care given to a 56-year-old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed performed on the left leg. What would be the best action of the nurse to correct this documentation? a. Erase or use correcting fluid to completely delete the error b. Draw a single line through the entry and rewrite it above or beside it. c. Use a permanent marker to block out the mistaken entry and rewrite it. d. Remove the page with the error and rewrite the data on that page correctly.

b. The nurse should not use dittos, erasures, or correcting fluids. A single line should be drawn through an incorrect entry, and the words "mistaken entry" or "error in charting" should be printed above or beside the entry and signed. The entry should then be rewritten correctly.

Nclex Q1 A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appendicitis. The physician has ordered 10mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines? Select all that apply. a. 6/12/15 0945 Morphine 10mg administered IV. Patient's response to pain appears to be exaggerated. M Patrick, RN b. 6/12/15 0945 Morphine 10mg adminstered IV. Patient seems to be comfortable. M Patrick, RN c. 6/12/15 0945 30 minutes following administration of morphine 10mg IV patient reports pain as 2 on a scale of 1 to 10. M Patrick, RN d. 6/12/15 0945 Patient reports severe pain in right lower quadrant. M Patrick, RN e. 6/12/15 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M Patrick, RN f. 6/12/15 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration

c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizationg such as "seems comfortable today." The nurse should never document an intervention before carrying it out.

Flow Sheet

documentation tool designed to efficiently record ROUTINE (round the clock data sets) aspects of nursing care. Think of Input and output , medications given each hour/ Well designed flow sheets enable nurses to quickly document the routine aspects of care that promote patient goal achievement, safety, and well being.

Case Management Model

Managed care's emphasis on quality, cost-effective care delivered within a limited time frame had led to the development of interdisciplinary documentation tools that clearly identify those outcomes that select groups of patients are expected to achieve on each day of care. The 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. One limitation of this model, however, is that it works best for "typical" patients with few individualized needs. At present, there is little consensus about which documentation tools are best for recording routine aspects of care and avoiding repetition.

Patient records are used for and have the usages of 1. Diagnostic and Therapeutic Orders 2. Care Planning 3. Quality process and Performance Improvement 4. Research 5. Decision Analysis 6. Education 7. Credentialing, Regulation, and Legislation 8. Legal Documentation 9. Reimbursement 10. Historical Documentation

1. Patient records also include diagnostic and therapeutic orders. Anyone reviewing the chart can find all the diagnostic studies ordered for the patient since admission. 2. Each Health care professional working with the patient has access to the patient's baseline and ongoing data and can see how the patient is responding to the treatment plan from day to day. 3. Quality process and Performance Improvement "Documentation is the primary source of evidence used to continuously measure performance outcomes against predetermined standards" Thus, records might be reviewed to evaluate the quality of care patients have received and the competence of the nurses providing the care. 4. Researchers might study patient records, hoping to learn how best to recognize or treat identified health problems from the study or similar cases. 5. Information from record review often provides the data needed by administrative strategic planners to identify needs as well as the means and strategies most likely to address those needs. Record review might reveal both underused and overused services, patients with prolonged stays who require special assistance, etc 6. Health care professionals and students reading a patient's record can learn a great deal about the clinical manifestations of particular health problems, effective treatment, modalities, and factors that affect patient goal achievement. 7. Documentation allows reviewers to monitor health care practitioners' and the health care facility's compliance with standards governing the profession and provision of care. 8. Patient records are LEGAL documents that might be used as evidence in court proceedings. One in four malpractice suits are decided on the basis of the patient's record. 9. Patient records are used to demonstrate to payers that patients received the intensity and quality of care for which reimbursement is being sought. 10. Because all entries on records are dated. the record has value as a historical document. Years later, information concerning a patient's past health care might be pertinent

Focus Charting

A documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format. (DAR) Moreover, The purpose of FOCUS CHARTING is to bring the focus of care back to the patient and the patient's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a patient and patient care. Topics that may appear in the focus column include patient concerns and behaviors, therapies and responses, changes of condition, and signitifcant events such as teaching, consultations, monitoring, management of activies of daily living, or assessment of functional health patterns. The narrative portion of FOCUS CHARTING uses the Data, Action, Response format. D: Patient's temperature at 1305 was 101.5 (oral). The rest of his vitals were stable and he was in no acute distress. A: Called Dr Smith and he ordered blood cultures X2, a CBC and a portable chest X-ray. After blood cultures were drawn, patient was given Tylenol at 1400. R: By 1500 patient's temperature was 99.8 (oral). Lab and X-ray results are pending. Will continue to monitor closely.

A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care." Explanation: Beside reports are driven to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

PIE Charting

A type of documentation system that does not develop a separate care plan because of its uniqueness, in fact, the plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this type of documentation system, a patient assessment is performed and documented at the beginning of each shift using pre-printed fill-in-the-blank assessment forms called FLOW SHEETs.. Patient problems identified in these assessments are numbered, documented in the progress notes, worked up using the PIE format and evaluated each shift. problem (P) intervention (I) evaluation (E) (PIE) Resolved problems are dropped from daily documentation. Continuing problems are documented and numbered each day. One advantage of this system is that it promotes continuity of care. It also saves time because like mentioned, there is no separate plan of care. The disadvantage of not having a formal plan care is that nurses need to read all the nursing notes to determine problems and planned interventions before initiating care.

Nursing Informatics

According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practices. The tangible benefits of this effort has become clear in; 1. Increasing accuracy and completeness of nursing documentation 2. Improvement in the nurse's workflow and an elimination of redundant documentation 3. Automation of the collection and reuse of nursing data

Collaborative pathways (may also be called Critical Pathway or care maps)

Case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions This timeline specifies the plan of care linked to expected outcomes

What is the primary purpose of the client record?

Communication Explanation: The primary purpose of the client record is to help health care professionals from different disciplines communicate with one another.

Change-of-shift Report

Communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped.

Discharge Summary

Description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals

Source-Oriented Record

Documentation system in which each health care group records data on its own separate form. Sections are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered in chronologically.

Occurrence/ Variance Charting

Documentation when a patient fails to meet an expected outcome or a planned intervention is not implemented, including the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate; typically used for variances that affect quality, cost, or length of stay

Graphic Record

Is a form used to record specific patient variable such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics

Consultation

Process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution.

Referral

Process of sending or guiding someone to another source for assistance

Narrative Notes

Progress notes written by nurses in a source-oriented record

Charting by exception (CBE)

Shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes. Benefits of this approach include less time needed for charting (freeing more time for direct patient care), a greater emphasis on significant data, easy retrieval of significant data, timely disciplinary communication. A significant drawback to charting by exception however, is its limited usefulness when trying to prove that high quality safe care was given if a negligence claim is made against nursing. As more facilities move to a totally electronic medical record, even facilities not previously using a CBE system are considering doing so.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care. Explanation: A nursing care conference is a meeting of nurses to discuss some aspect of a client's care. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 16: Documenting, Reporting, Conferring, and Using Informatics, p. 363.

Medication Record

The patient's medication record must include documentation of all the medications administered to the patient (drug, dose, route, time), the nurse administering the drug, and for some medications (e.g., analgesics), the reason the drug was administered and its effectiveness.

Progress Notes (Utilized by SOAP, PIE, focus charting, charting by excepting and the case management model)

The purpose of progress notes is to inform caregivers of the progress a patient is making toward achieving expected outcomes. The method used to record the patient's progress depends on the documentation system being used. Common examples include narrative nursing notes, SOAP notes, PIE notes, focusing charting, charting by excepting, and the case management model.

Methods of documentation

While the different methods of documentation might initially seem confusing, each is designed to achieve certain aims. Understanding a variety of systems help nurses adapt quickly in new practice settings.

Documentation

Written, legal record of all pertinent interventions with the patient-assessments, diagnoses, plans, interventions, and evaluations

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? a. Admission sheet b. Admission nursing intervention c. Activity flow sheet d. Graphic record

d. Graphic record. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the activity flow sheet.

Read Back

A process in which a nurse or other health care provider repeats a verbal order back to a physician to ensure that it was correctly heard and interpreted. Verbal orders may not be given, received, or executed under any other circumstances. Read Back is necessary.

Which of the following is not a purpose of the medical record?

Contract Explanation: Medical records are legal documents, communication tools, and assessment tools. They are used for care planning purposes, quality assurance purposes, for reimbursement, research, and education.

Problem-Oriented Medical Record (POMR)

Originated by Dr. Lawrence Weed in the 1960's The POMR is organized around a patient's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of patient problems and contributes collaboratively to the plan of care. Progress notes clearly focus on patient problems. The POMR includes the defined database, problem list, care plans, and progress notes. Lack of: Documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes.

Care Plan

Patient records must communicate the patient's problems or diagnoses; related goals, outcomes, and interventions; and progress notes or resolution of the problems. the nursing plan of care may be written separately or incorporated into a multidisciplinary plan. In a traditional plan of nursing care, nursing diagnoses, goals and expected outcomes, and nursing interventions are written for each patient. Standardized plans of care may also be used that identify common problems and related care for select patient groups. These generally incorporate standards of high quality care, but unless such care plans are individualized, they might not sufficiently address individual patient needs. Formats for plans of care vary greatly.

Patient Record

The primary purpose of the patient record is to help health care professionals from different disciplines (who interact with the patient at different times) communicate with one another. A compilation of a patient's health information; the patient record is the only permanent legal document that details the nurse's interactions with the patient. The Joint commission specifies that nursing care data related to patient assessments, nursing dx or patient needs, nursing interventions, and patient outcomes are PERMANENTLY integrated into the patient record.

Acuity Records

Twenty-four-hour reports are increasingly used in conjunction with acuity reports, with which nurses rank patients as high-to-low acuity in relation to both the patient's condition and need for nursing assistance and intervention. A trauma patient whose condition is changing rapidly and who requires intensive nurse monitoring and intervention merits a higher acuity rank than a patient whose condition is stable.

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the order in which they should be performed. a. "I am calling about Mr. Sanchez in room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." d. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." e. "Mr. Sanchez was admitted two days ago following a diagnosis of pancreatic cancer." f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered.

d, a, e, b, f, c