Nursing Documentation and Informatics

HITECH

- Health Information Technology for Economic and Clinical Health Act 1. to improve patient safety 2. decrease costs 3. improve quality of care

What committee and commission maintains institutional accreditation and minimize liability?

- National Committee for Quality Assurance (NCQA) - The Joint Commission (TJC)

What are the purposes of the health record?

1. communication: so nurses and other health care personnel can communicate about the patient and his or her care. 2. legal record: that the facility has record of the patient and what they are exactly there for / for billing and information purposes as well 3. auditing and monitoring 4. research and education 5. reimbursement

How does one handle and dispose of information in a healthcare facility?

1. discard papers in a receptacle or shred them 2. de identify patient (do not use patient identifiers) 3. do not give out your password/code to the computer because only you are obligated to look in your own patient's health record. NOT anyone else who is not taking care of that patient.

With nursing guidelines and documentation, what are the six components that are needed for that?

1. factual 2. accurate 3. current 4. appropriate use of abbreviations 5. organized 6. complete

Case Study Mrs. Smith is a 93 year old patient with fractures in her lower spine resulting from severe osteoarthritis (brittle and breaking bones - wear and tear) that can be treated with surgery. She reports her pain as a 10 out of 10. While completing Mrs. Smith's admission history, you find out that she had a total knee replacement 3 years ago and pain was not well controlled at the time. Mrs. Smith tells you, "I'm dreading surgery." Last time, I had such pain when I got out of bed." 1. What is the subjective data in this case study? 2. What is the PIE note in this case study?

1. subjective: Mrs. Smith reported that her pain as a 10 out of 10. 2. PIE note Problem: fractures in her lower spine Intervention: surgery Evaluation: Mrs. Smith is dreading surgery

What is ADPIE?

A: assessment D: diagnosis P: planning I: implementation E: evaluation

What is DAR?

D: data A: action R: response

What is PIE?

P: problem I: intervention E: evaluation

What is SOAP?

S: subjective data O: objective data A: assessment P: planning

EMR (electronic medical record)

an individual's one time record (e.g. from a doctor's office visit)

EHR (electronic health record)

an individuals lifetime record

Quick Quiz A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paperwork, the nurse needs to record: a. an interpretation of patient behavior b. objective data that are observed c. lengthy entry using lay terminology d. abbreviations familiar to the nurse

b. objective data that was observed

Quick Quiz 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 the 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

c. reimbursement issues related to patient care and procedures may be of concern.

complete

contains appropriate and essential information.

1. a vital aspect of nursing 2. used to log; a. patient assessment b. nursing diagnoses c. nursing interventions d. patient responses (evaluation)

documentation

current

entries have to be recorded at a timely manner because it could negatively alter a patients care (unsafe care). e.g. vital signs, pain assessment, administrations of medications and treatments.

organized

notes are clear, concise, to the point, and presented in a logical order.

factual

objective facts about what a nurse observes, hears, palpates, and smells. e.g. avoid using terms like appears, seems, or apparently. - "patient's heart rate 110bpm, respiratory rate is slightly labored at 22 breaths/min, and patient states, "I feel very nervous."

accurate

using exact measurements to help determine a patient's condition - if it changed in a positive or negative way e.g. "intake 360 mL of water" is more accurate than "patient drank an adequate amount of water."