Health Record Flashcards
1
Q
the health record
A
- contains info about individuals health and services provided
- HPCs can access health records only if part of persons circle of care
- hospital & long term care charts contain different sections to organize information
2
Q
health record examples
A
- admission sheet
- history
- physician orders
- diagnostic results
- medical/surgical reports
- flow sheets
- interdisciplinary notes
3
Q
health record accurate recording/documenting
A
- legislation requires documentation
- anything entered needs to be considered as having potential to become evidence
- communication with team members
- needs to be detailed, clear & concise
- what is recorded and how it is worded are important
- nurses cannot diagnose
- ensure no labels are used
4
Q
purposes of documentation
A
- identify care and services a client requires or care that was provided
- inform quality improvement processes
- review client outcome info to reflect on practice
- valuable source for data collecting in health research
- source of info in making funding and resource management and decision
- legal investigation and other legal proceedings
5
Q
methods of documentation
A
- focus charting
- narrative
- charting by exception
6
Q
focus charting
A
- identify what you’re charting
- document about one topic and highlight important topics
7
Q
narrative
A
- told in chronological order
- not broken down into components
8
Q
charting by exception
A
- only document something that is abnormal
9
Q
health information
A
- personal health information protection and access act (PHIPAA)
- all jurisdictions have laws regarding health info & privacy
- agency that creates physical chart owns & maintains
- individuals health info belongs to them
- clear consent is required to share health info with 3rd party
- individuals have right to access their health info
10
Q
individuals have right to access their health info but…
A
- they cannot take physical chart or amend it
- physician has 30 days to give access at no additional charge
- supervision is necessary
- changes may be made upon agreement of provider
- changes must be initialed and dated
11
Q
storage and disposal
A
- must be maintained if physician stops practising
- servers must be professionally wiped & paper document shredded in confidential manner
- records must be safe and secure
- records kept for at least 10 year from last date of entry
12
Q
keeping records safe and secure
A
- protected from fire, encrypted software, and passwords
- access must be restricted to only those necessary
- electronic system must have audit trial
13
Q
Canada privacy act
A
- 1983
- limits private info collected by federal govt
- cant collect more info than they need to know
- restricts use and sharing, cant share between govt departments
- allows individuals access to any info federal govt has about them
- Alberta, Manitoba, Saskatchewan, & Ontario have own legislation to specific HCPs
14
Q
PIPEDA
A
- personal info protection and electronic documents acts
- deals with info collected by private sector
- protects personal info that is collected, used, or disclosed
- consent based legislation
- personal health info is usually legislated by provinces/territories as it is related to health care
- NB- personal health info privacy and access act
15
Q
confidentiality
A
- HCPs moral and legal obligation to maintain privacy of patient info
- within circle or care
- legal access to patient info
- abide to confidentiality agreements
- know/follow institutional policies
- HCPs act are to keep info secure and restricted
- some situations where HCPs are obligated to release confidential info
