Ch. 26: Documentation/Informatics Flashcards
Purposes of documentation:
It provides a detailed account of the level of quality of care delivered to patients; effective documentation ensures continuity of care, saves time and minimizes the risk of errors
Documentation:
Anything written or printed in which you rely as record or proof of patient actions and activities; must be accurate, comprehensive, and flexible enough to retrieve clinical data, maintain continuity of care, track patient outcomes, and reflect current standards of nursing practice
Why is documentation and reporting an extremely important responsibility of a nurse?
Healthcare environment creates challenges for accurate documentation and reporting so quality of care, standards of regulatory agencies and system, and legal guidelines are important.
Confidentiality
Nurses are legally and ethically obligated to keep patient information confidential; cannot discuss patient’s exam, observation, conversation, diagnosis, or treatment with other patients or staff not involved in patient care, only staff directly involved can have access to records
T/F Do patients have the right to request copies and read their medical records?
True. Check institution policy for sharing records, most patients are required to give written permission for release of medical information
HIPAA (Health Insurance Portability and Accountability Act)
Legislation to protect patient privacy for health information; governs all areas of patient info and management of info; providers required to notify patients of privacy policy and make effort to get written acknowledgment of notification; disclosure or requests of health info should be limited to a minimum
T/F Nurses can use healthcare records for data-gathering, research, or continuing education.
True. As long as a nurse uses a record as specified and permission is granted this is permitted
List some examples that show compliance with HIPAA:
Use patient’s medical records for info needed to provide safe and effective patient care; do not share info with classmates (except for clinical conferences); do not access medical records of other patients on the unit; within student clinical practice do not include patient identifiers; never use printed material from electronic health record for personal use
Standards
Institution standards and policies can dictate frequency of documentation; nurses are expected to meet the standard of care for every nursing task they perform; patient records can be used as evidence in court if standards are not met
Accreditation
Process where professional institution or non-governmental agency grants recognition to a school or institution for demonstrated ability to meet predetermined criteria
Describe current documentation standards required for all patients that are admitted to a healthcare facility.
Required to have an assessment of physical, psychosocial, environmental, self-care, knowledge level, and discharge planning needs.
The joint commission (TJC) standards requirements:
The documentation be within the context of the nursing process and include evidence of patient and family teaching and discharge planning.
Consultation
Help of a specialist is sought to identify ways to handle problems in patient management or in planning and implementing programs
Referral
Arrangement for services by another care provider
Interdisciplinary communication within the healthcare team (methods):
Effective communication among members of the healthcare team; can be via patient’s record or chart, oral, written or audiotaped exchanges of info, change of shift report, telephone report, handoff report an incident reports
Purposes of records:
Communication, legal documentation, financial billing, education, research, and auditing\monitoring
Records: Communication-
A way that healthcare members communicate patients needs and progress, their therapies, their consultations, patient education and discharge planning. Most accurate and current source of info about patient’s health status. This facilitates safe, effective, and timely patient-centered decisions
Records: Legal aspect of documentation-
Accurate documentation is best defense for legal claims associated with nursing care. Documentation must indicate clearly that a patient received individualized, goal directed nursing care based on nursing assessment. Must be exact and must follow agency standards. Best achieved when you chart immediately after providing care.
Legal Documentation: List some common charting mistakes that result in malpractice.
Failure to record the following:
-pertinent health or drug info
-nursing actions
-medications given
-drug reactions or changes in patient condition
-discontinued medications
And writing illegible or incomplete records
Diagnosis-related groups (DRGs)
Group of patients classified to establish a mechanism for health care reimbursement based on the length of stay. Classification based on following variables: primary and secondary diagnosis, co-morbidities, primary and secondary procedures, and age
Records: Education-
You can identify patterns of information in different patients records who have similar health problems. With that information, you can learn to anticipate the type of care required for a patient
Records: Research-
After obtaining approval nurse researchers can use patients’ records for research studies to get data on clinical disorders, complications, use of specific therapies, recovery from illness, and death
Records: Auditing and Monitoring-
Hospitals have quality improvement programs to conduct objective ongoing reviews of patient care. This keeps nurses informed of standards of nursing practice to maintain excellence in nursing care. Institutions and accrediting groups established standards for quality care. And any deficiencies identified during monitoring is shared with staff to make changes in policy or practice
What are the five important characteristics of quality documentation and reporting?
They must be factual, accurate, complete, current, and organized
What does a factual record contain?
Descriptive, objective information about what a nurse sees, hears, feels, and smells.
Objective and subjective data:
Objective data includes observation of patients behaviors and signs of problems. Subjective data is what the patient states and patients exact words should be quoted. Objective data should support subjective data so charting is as descriptive as possible
Documentation: Accurate
Exact measurements; data is clear and easy to understand; using abbreviations carefully to avoid misinterpretation; using correct spelling; all entries in medical records must be dated and authors must be easily identified by using full name of caregiver.
Documentation: Complete
It contains appropriate and essential information; describes the nursing care you administered and includes the patient’s response; describes data in great detail when relevant
Documentation: Current
Entries must be timely; delays can lead to unsafe patient care; use military time
Document following activities at time of occurrence:
Vitals; pain assessment; admin of meds and treatments; prep for tests or surgery or preoperative checklist; change in status and who is notified; admission, transfer, discharge, or death; treatment for sudden changes in status; patient’s response to treatment or intervention
Documentation: Organized
Communicate information in a logical order; notes should be concise, clear, and to the point; if situation is complex make a list of what should be included before entry of data; TLAN and organize your data so it is logical
What are different methods of documentation?
Paper and electronic health records; narrative documentation; problem-oriented medical record; source records; charting by exception; case management plan in critical pathways
Paper health records
Traditional form of documentation; episode oriented with a separate record for each patient visit to a healthcare agency. Since each visit is separated, key information such as allergies, medications or complications may be lost from one visit to the next which jeopardizes patient’s safety
Electronic health record (EHR)
An electronic record of patient health information generated whenever a patient accesses medical care in any healthcare delivery setting
Electronic medical record (EMR)
Part of the electronic health record that contains patient data gathered in a healthcare setting at a specific time and place; EHR & EMR are terms that are used interchangeably
What are advantages of an EHR?
It’s a means to compare ongoing clinical data about a patient with the original baseline information and maintaining an ongoing record of the patient’s health education. It also offers easier access to quality data for research and automates evidence-based guidelines
What is narrative documentation?
Traditional method for recording nursing care in a story-like format. Has disadvantages because it tends to be repetitious . time-consuming and you must sort through much information to locate desired data
Problem-oriented medical record (POMR)
A method that emphasizes patients’ problems where data is organized by problems and diagnosis. Each member of the healthcare team contributes to a list of identified patient problems and coordinates a common plan of care.
List the major sections of POMR
Database, problem list, care plan, progress notes
POMR: database
Includes all available assessment information pertaining to the patient; foundation for identifying patient problems and planning care and accompanies patients through future visits
POMR: problem list
A single problem list that is created after data is analyzed and problems are identified. They include: physiological, psychological, social, cultural, spiritual, developmental, and environmental needs. Once the needs are met, record date and highlight or draw line through it.
POMR: care plan
Include nursing diagnosis, expected outcomes, and interventions for each problem.
POMR: progress notes
SOAP (subjective, objective, assessment, plan)
SOAPIE (above list w/ intervention and evaluation)
PIE (problem, intervention, evaluation)
Explain the difference between SOAP and PIE.
SOAP method originates from medical records; includes assessment
PIE has a nursing origin and does not include assessment information; The notes are numbered are labeled according to the problems and once problems are resolved it is dropped from the daily documentation
Focus charting (DAR)
Charting methodology for structuring progress notes according to the focus of the note. Each note includes data, actions, and patient response
DAR notes
Data (subjective, objective)
Action (nursing intervention)
Response (from patient)
DAR note addresses A sign or symptom, condition, nursing diagnosis, behavior, significant event, or change in patient’s condition
Source record
Organization of a patient’s chart so each discipline has a separate section to record data. Unlike POMR, it’s not organized by problems, it’s organized by disciplines such as nursing, medicine, therapies.
Charting by exception (CBE)
Shorthand method for documenting normal findings and routine care; data is entered only when there’s an exception from a normal or expected situation; reduces documentation time and highlights trends or changes in patient’s condition
Case management
A system for delivering health care to a patient or group of patients across an episode of illness or continuum of care. Includes assessment and developing a plan of care, coordination of services, referral, follow up and is usually assigned to one professional.
Critical pathways
Interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established timeframe
Variances
Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway. May be positive or negative.
If a patient progresses more rapidly than expected is that a positive variance or a negative variance?
Positive variance-use Foley discontinued a day early.
Negative variance-pulmonary complications after surgery requiring O2 therapy
Admission nursing history forms
History form completed when patient admitted to a nursing unit; guides nurse through complete assessment and identifies relevant nursing diagnosis or problems; baseline data provided to compare any changes in patient condition
Flow sheets
Documents on which frequent observations or specific measurements are quickly and easily recorded; accessible to entire healthcare team and members can quickly see patient trends over time and decrease time spent on writing narrative notes
Kardex (patient care summary)
Tradename for card filing system that allows quick reference to the particular need of the patient for certain aspects of nursing care; portable file or notebook that organizes information for quick reference and eliminates the need for always referring to the chart for info
Standardized care plans
Written care plans used for groups of patients who have similar healthcare problems; useful when conducting quality improvement audits and they improve continuity of care among professional nurses
Discharge summary forms
Patients are prepared for an effective, timely discharge from a healthcare institution; discharge needs to result in desirable outcomes; documentation includes medications, diet, community resources, follow-up care, and contact person in case of emergency or for questions
Acuity records
Entries describing patient care activities made over a 24 hour period; activities are then translated into reading score, or acuity score, that allows for a comparison of patients who vary by severity of illness
Home care documentation
Nurse gathers assessment, develops a plan of care can gathers info about changes in the patient’s healthcare status; information used for reimbursement comes from a patient’s medical record; some parts of the record remain in the home while other parts are in the office so duplication is necessary
Long-term healthcare documentation
Can be challenging; residents in a long term care agency getting funding from Medicare and Medicaid programs use the Resident Assessment Instrument/Minimum Data Set (RAI/MDS); standardize protocols for assessment and care planning, minimum data set to promote quality improvement within and across facilities
Reporting
Verbal report must be timely, accurate, and relevant; common reports used by nurses include hand-off, telephone, and incident reports
Hand-off report
When one healthcare provider transfers care of patient to another healthcare provider; standardized communication is used for patient safety; includes up-to-date info about condition, required care, treatments, medications, services, or any changes
What is the purpose of a handoff report?
To provide better continuity and individualized care for patients; can be given face-to-face, in writing, or verbally over the phone or via audio recording
Describe an effective hand-off report
Quick and efficient; provides a baseline for comparison’s and indicates the kind of care anticipated for the next nurse; organized and concise to help set goals and anticipate patients needs and lessens the chance of overlooking important information
Telephone reports
When significant events or changes in patient’s condition have occurred; need to include clear, accurate, and concise info
Sentinel events
Communication problems that often arise during telephone reports; accounts for 60% of the worst type of medical errors
SBAR
Situation, background, assessment, recommendation; standardize telephone communication relaying significant events or changes in condition and is a strategy designed to improve patient safety
SBAR: Situation
Include admitting and secondary diagnosis and the problem the patient is having at the moment
SBAR: Background
Info includes pertinent medical history, previous lab tests and treatments, psychosocial issues, allergies, current code status
SBAR: Assessment
Include significant findings in head to toe physical assessment, recent vital signs, current treatment measures, restrictions, recent lab results and diagnostics, pain status
SBAR: Recommendation
You suggest a plan of care and what needs to be addressed
What is a “read back”?
You document every phone call you make it to a healthcare provider and you include: when you called, who called, who was called, to whom info was given, what info was given, what info was received, and verification of the information with the provider
Telephone (TO) and verbal orders (VO)
A TO is when a healthcare provider gives an order over the phone to an RN; a VO involves the healthcare provider giving orders to an RN while standing near each other; nurse receiving the TO or VO writes down the order and enters it as it is being given then read the order back to the healthcare provider and receives confirmation that the order is correct
Incident (occurrence) reports
Confidential document that describes any patient accident while the person is on the premises of the healthcare agency; not to be documented in the medical record
Health informatics
The application of computer and information science for managing health-related data; focus on the patient in the process of care; goal is to enhance the quality and efficiency of care provided; driven by the Health Information Technology for Economic and Clinical Health Act (HITECH)
Nursing informatics
Specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge of nursing practice; ability to gather data, use information and critically think to care for patients
Information technology (IT)
Management and processing of information, generally with the assistance of computers
Healthcare information system (HIS)
Group of systems used within a healthcare organization to support and enhance healthcare; includes two major types: clinical information systems (CISs) and administrative information systems and they are used together to gather data more efficiently
Advantages of nursing informatics
Allows nurses to view data, collect information, support and enhance nursing practice, reduce errors and improve patient safety.
North American Nursing Diagnosis Association (NANDA)
And advanced form of nursing information systems (NIS) that incorporates standardized nursing languages; drop-down menu lists are offered
Clinical decision support systems (CDSSs)
Computerize programs used within the healthcare setting to support decision-making; Information is current, evidence-based, and updated; i.e. it notifies healthcare providers if their allergies before ordering medications
Computerized provider order entry (CPOE)
Process by which a healthcare provider directly enters orders for patient care into the hospital information system
