Lesson 9: Other Sources of Client Data Flashcards
Informal oral consideration of a subject
by two or more health care personnel to
identify a problem or establish strategies
to resolve a problem.
● Individual conference
● Handover, endorsement to HCPs
● Discussion about the condition of the
patient.
Discussion
Oral, written, or computer-based
communication intended to convey
information to others.
● For instance, nurses always report on
clients at the end of a hospital work
shift.
● Ex. incidental report
Report
● Also called chart or client record
● Formal, legal document that provides
evidence of a client’s care
● Can be written or computer based
● Although health care organizations use
different systems and forms for
documentation, all client records have
similar information.
Record
The process of making an entry on a
client record.
Recording, Charting, or Documenting
Each health care organization has
policies about recording and reporting
client data, and each nurse is
accountable for practicing according to
the standards. So agencies also indicate
which nursing assessments and
interventions can be recorded by
registered nurses and which can be
charted by unlicensed personnel.
Ethical and Legal Considerations
Requires client record to be timely,
complete, accurate, confidential and
specific to the client.
● Healthcare reform has been pivotal in
the process of increasing the use of
electronic health records.
JCAHO
the nurse has a duty to maintain
confidentiality of all patient information.”
The client’s record is also protected
legally as a private record of the client’s
care, so access to the record is
restricted to health personnel or
professionals
American Nurses Association Code of
Ethics (2001)
Hallmark of nursing accountability is
accurate documentation of actions and
outcomes of delivered care is the
hallmark of nursing accountability.
Code of Ethics for Filipino Nurses
regulations maintain the
privacy and confidentiality of Protected
Health Information
HIPAA
Confidentiality of all patient information
● Client’s record protected legally as a
private record of client’s care
○ Legal document which can be
used against the nurse in the
court.
● Responsibility in using records for the
purpose of education and research
Ethical and Legal Considerations
Accurate client record provides details about
the care a client has received and the client’s
overall response to care. So accurate
documentation provides the staff with a means
of accountability and reflection on the delivery
of client care
Purposes of Client Record
Prevents fragmentation,
repetition, and delays in care.
○ Record serves as the vehicle by
which different health
professionals who interact with
the client communicate with each
other.
Communication
Nurses use baseline and ongoing
data to evaluate effectiveness of
the care plan.
○ Each health professional uses
data from the client’s record to
plan care for that client, so a
primary care provider, for
example, may order a specific
antibiotic after establishing that
the client’s temperature is
steadily rising and the laboratory
tests reveal the presence of a
certain microorganism.
Planning client care
Review client records for quality
assurance purposes. an
accrediting agency such as the
Joint Commission, may review
client records to determine if a
particular health agency is
meeting its stated standards.
Auditing Health Agencies
Treatment plans for a number of
clients with the same health
problems can yield information
helpful in treating other clients.
○ The information contained in a
record can be a valuable source
of data for research
Research
Students in health disciplines
often use client records as
educational tools. A record can
frequently provide a
comprehensive view of the client,
the illness, effective treatment
strategies, and factors that affect
the outcome of the illness.
Education
Documentation also helps a
facility receive reimbursement
from the federal government. So
for a facility to obtain payment
through Medicare, the client’s
clinical record must contain the
correct diagnosis group codes
and reveal that the appropriate
care has been given
○ So codable diagnosis are
supported by accurate thorough
recording by nurses.
Reimbursement
Admissible in court as evidence
unless client objects because
information client gives to
primary care provider is
confidential.
Legal Documentation
Identify agency needs such as
overutilized and underutilized
hospital services.
○ Records can be used to establish
the cost of various services and
to identify those services that
cost the agency money and those
that generate revenue.
● Health Care Analysis
Primary Source of Data
a. Patient
a. Family members
b. Significant Others
c. Medical Records
d. Diagnostic Procedures
i. CBC, WBC, platelet,
sodium, potassium etc.
Secondary Source of Data
a. Narrative Charting
- Source-Oriented Record
a. Database
b. Problem list
c. Plan of care
d. Progress Notes
● SOAP
● SOAPIER
Problem-Oriented Medical Record
. legal name, birthday, age,
gender, SSS number, address,
marital status, closest relatives or
person to notify in case of
emergency, time date, and
admitting diagnosis, if there are
any food or drug allergies, name
of admitting primary care
provider, insurance information,
and any assigned diagnosis
related group.
Admission sheet
. Findings from the Initial Nursing
History and Physical Health
Assessment
Initial Nursing Assessment
body temperature, pulse rate,
respiratory rate, blood pressure,
the daily weight, and special
measurements such as fluid
intake and output and oxygen
saturation
Graphic Record
