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
