Interprofessional Communication Within the Health Record Flashcards
Legal Documentation
Accurate documentation is one of the best defenses for legal claims associated with nursing care. To limit liability, your documentation needs to follow
organizational standards, which include a clear description of
individualized and goal-directed nursing care you provide based on your
nursing assessment. Documenting all aspects of the nursing
process is a critical nursing responsibility that limits nursing liability by
providing evidence that you maintained or exceeded practice standards
while taking care of patients. Mistakes include: (1) failing to record pertinent health or drug
information, (2) failing to record nursing actions, (3) failing to record
medication administration, (4) failing to record drug reactions or changes
in patients’ conditions, (5) incomplete or illegible records, and (6) failing to
document discontinued medications.
Reimbursement
Documentation of patient care
allows one to determine the severity of a patient’s illness, the intensity of
services received, and the quality of care provided during an episode of
care. Insurance companies use this information to determine payment or
reimbursement for health care services. Diagnosis-related groups (DRGs)
are classifications based on a hospitalized patient’s primary and secondary
medical diagnoses that are used as the basis for establishing Medicare
reimbursement for patient care. Hospitals are reimbursed a predetermined
dollar amount by Medicare for each DRG. Private insurance carriers and
auditors from federal agencies review records to determine the
reimbursement that a patient or a health care agency receives (Bauder
et al., 2017). Accurate documentation of nursing services provided, as well
as the supplies and equipment used in a patient’s care, clarifies the type of
treatment a patient received and supports accurate and timely
reimbursement to a health care agency and/or patient.
Auditing and Monitoring
Quality patient care depends on the ability of all members of the
interprofessional team to communicate effectively and in a timely manner.
Regulations from
agencies such as The Joint Commission (TJC) and the Centers for Medicare
and Medicaid Services (CMS) require health care institutions to monitor
and evaluate the quality and appropriateness of patient care (TJC, 2018; US
Centers for Medicare & Medicaid Services, 2019). Audits of health records
offer information on recurrent health care problems, specific patient
incidents, and whether health care providers follow standards of care.
Health care record audits help to identify areas for improvement and staff
development.
Education
Health care records are a rich source of information about a patient’s
health care. Reading the record of a patient for whom you are assigned to
care is an effective way to learn the nature of a patient’s condition and
response to treatment. Over time, as you care for patients with similar
diagnoses or problems, the information gained from those patients’
records allows you to identify paerns and trends and to build your
clinical knowledge. As you identify paerns associated with specific
diseases and conditions, you are able to anticipate the type of care your
patients require and how patients respond to treatment.
Research
De-identification is a process used to prevent a person’s identity from
being connected with information. For example, when a data form is used
to collect information from a health record a patient’s name or Social
Security number is not entered; instead a random number is used for
labeling and categorizing the form. After obtaining
appropriate approval from an Institutional Review Board (IRB) of a health
care agency or hospital, a nurse researcher reviews patients’ records in a
research study to collect information on a particular health problem. For
example, if a nurse researcher suspects that early ambulation decreases the complication rate in postoperative patients, the researcher could review
the records of select surgical patients to compare the rates of postoperative
complications following early versus late ambulation.
The Shift To Electronic Documentation
To facilitate communication among health care providers and improve
patient safety, the American Recovery and Reinvestment Act (ARRA) of
2009 set a goal that all health care records would be kept electronically as
of 2014 . HITECH established
provisions to promote the meaningful use of health information
technology (HIT) to improve the quality and value of health care
(Compliancy Group: HIPAA Done Right, 2019). Meaningful use requires
that use of an electronic health record system (EHRS) results in improved
quality, safety, and efficiency of health care; increases health care
consumers’ active involvement in their care; increases coordination of
health care delivery; advances public health; and safeguards the privacy
and security of personal health records (Stimson & Bodruff, 2017). The
goal of the ARRA was to have all health care records maintained
electronically by 2014.
The term electronic medical record (EMR)
refers to a patient’s record within an integrated health care information
system for an individual visit to a health care provider’s office or for an
individual admission to an acute care setting that allows for seamless
documentation of the progression of care. To meet agreed-on standards,
EHRs are expected to have the following attributes or components (Hebda
et al., 2019):
• Provide a longitudinal or lifetime patient record by linking all
patient data from previous health care encounters.
• Contain a problem list that indicates current clinical problems for
each health care encounter, the number of occurrences associated
with all past and current problems, and the current status of each
problem.
• Use accepted standardized measures to evaluate and record health
status and functional levels.
• Provide a method for documenting the clinical reasoning or
rationale for diagnoses and conclusions that allows clinical
decision making to be tracked by all providers who access the
record.
• Support confidentiality, privacy, and audit trails.
• Provide continuous access to authorized users at any time, and
allow multiple health care providers access to customized views of
patient data at the same time.
• Support links to local or remote information resources such as
databases using the Internet or intranet resources based within an
organization.
• Support the use of decision analysis tools.
• Support direct entry of patient data by providers.
• Include mechanisms for measuring the cost and quality of care.
• Support existing and evolving clinical needs by being flexible and
expandable.
information into one record, regardless of the number of times a patient
enters a health care system. An EHR also includes results of diagnostic
studies that may include diagnostic images (e.g., x-ray or ultrasound
images) and decision support software programs. Because an unlimited
number of patient records potentially can be stored within an EHR system,
health care providers can access clinical data to identify quality issues, link
interventions with positive outcomes, and make evidence-based decisions
(Rajkovića et al., 2018) The key advantages of an EHR for nursing include
a means for nurses to compare current clinical data about a patient with
data from previous health care encounters, maintain ongoing symptom
management, and provide an ongoing record of health education provided to a patient and the patient’s response to that information.
Maintaining Privacy, Confidentiality, and Security
of the Health Care Record
Nurses are legally and ethically obligated to keep information about
patients confidential. Only members of the health care team who are
directly involved in a patient’s care have legitimate access to a patient’s
health record. You discuss a patient’s diagnosis, treatment, assessment,
and any personal conversations only with members of the health care team
who are specifically involved in the patient’s care. Do not share
information with other patients or with health care team members who are
not caring for the patient. Patients have the right to request copies of their
medical record and read the information. To eliminate barriers that potentially delay access to care,
HIPAA requires providers to notify patients of privacy policies and to
obtain wrien acknowledgment from patients indicating they received this
information. Under HIPAA, the Privacy Rule requires that disclosure or
requests regarding health information are limited to the specific
information required for a particular purpose. It is unethical to view health records of
other patients, and breaches of confidentiality will lead to disciplinary
action by employers and potentially dismissal from work or nursing
school. To protect patient confidentiality, you must ensure that any
electronic or wrien materials you use in your student clinical practice do
not include patient identifiers (e.g., name, room number, date of birth,
demographic information). Never print material from an EHR for personal
use; any information printed must be for professional use only and should
not include identifiable information.
Handling and Disposing of Information
Destroy (e.g.,
shred or place in a locked receptacle designated for collection of material
that is to be shredded) anything that is printed when the information is no
longer needed. Nursing students should not print information from the
health record to take away from the clinical agency to complete wrien
assignments for clinical.
