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
activity, diet, bathing and
elimination record
Daily Care Record
the Fluid balance record, skin
assessment or the braden scale
push tool
Special Flow Sheets
name, dosage, drought, time,
date of regularly administered
medication, name or initials of
persons administering the
medication
Medication Record
pertinent assessment of clients
specific nursing care, including
teaching and clients responses,
clients complaints, and how client
is coping
Nurse’s Notes
past and family medical history,
present medical problems,
differential or current diagnosis,
findings of physical examination
by the primary care provider
Medical History and Physical
Examination
medical records for medications,
treatments, and so on.
Physician’s order form
a. observations of the doctors and
the treatments given in the
client’s progress
Physician’s progress notes
. records by medical and clinical
specialist
Consultation record
laboratory reports, CBC, sodium
potassium, Xray reports, CT scan
reports
Diagnostic reports
physical therapies, and
respiratory therapies. If your
patients are referred to those
other health care professionals.
Consultation reports
started on admission and
completed on discharge. So this
includes nursing problems,
general information and referral
data
Client discharge plan and summary
established by Lawrence Weed in the
1960
● Data arranged according to client
problems rather than the source of the
information.
● Health team contributes to the problem
list, plan of care, and progress notes.
● Plans for each active or potential
problem are drawn in progress notes
recorded for each problem.
Problem-oriented Medical Record
All information known about the
client when the client first enters
the health care agency
Database
Listed in order in which they are
identified and others resolved
○ Derived from the database, it is
usually kept at the front of the
chart and serves as an index to
the numbered entries in the
progress notes
Problem List
Made with reference to active
problems
○ Generated by individual who lists
the problems
○ Primary care providers -
physicians orders or medical care
plans, nurses - nursing orders or
nursing care plans.
○ The written plan in the record is
listed under each problem in the
progress notes and is not isolated
as a separate list of orders.
Plan of Care
PIE
Problems
2. Interventions
3. Evaluation
- Data
- Action
- Response
Focus Charting
Intended to make the client and client
concerns and strengths the focus of
care, so three columns for recording are
usually used the date and time, focus,
and progress notes.
● The focus may be a condition, a nursing
diagnosis, a behavior or a sign or
symptom, an acute change in the
client’s condition, or a client’s strength.
Focus Charting
Documentation system in which only
abnormal or significant findings or
exceptions to norms are recorded.
Charting by Exception (CBE)
include graphic records of vital
signs, braden assessment tool for
the skin
Flow Sheets
These are documentation by
reference to the agency’s printed
standards of nursing practice
eliminates much of the repetitive
charting of routine care
Standards of Nursing Care
So if all of the standards are not
implemented,
an asterisk on the
flow sheet is made with reference
to the nurse’s notes for all
exceptions to the standards are
described in narrative form on
the nurses notes
In the CBE system, all flow
sheets are kept at the client’s
bedside to allow immediate recording and to eliminate the
need to transcribe data from the
nurse’s worksheet to the
permanent record.
Bedside access to chart forms
Used to manage the huge volume
of information required in
contemporary health care, so that
is, the EHR can integrate all
pertinent client information into
one record
Electronic Health Records (EHR)
Emphasizes quality
● Cost effective care delivered within an
established length of stay.
● This model uses a multidisciplinary
approach to planning and documenting
client care using the critical pathways.
So these forms identify the outcomes of
care along with the interventions
necessary for each day.
Case Management
a goal that is
not met is called a
is a deviation from what was
planned on the critical pathway.
variance.
It is the knowledge of events in
the patient’s illness, progress in
his or her recovery and the type
of care given by the hospital
personnel.
○ This is the chart of the patient
itself.
. Patient Clinical records
A separate set of records is
needed for each staff member,
giving details of their sickness
and absences, their career and
development activities and a
personal note.
○ Records of each staff in the unit.
So each staff will have their own
clearbook with names, leave,
personal data sheet, achievement
within the year, if they undergo
Masters or PhD.
Individual Staff Records
These are the records pertaining
to a particular ward.
i. Circular record
ii. Round book
iii. Duty roaster
iv. Ward indent book
v. Ward inventory book
vi. Staff patient assignment
record
vii. Student attendance and
patient assignment record
Ward Records
○ Treatment register
○ Admission and discharge register
○ Personnel performance register
○ Organizational chart
○ Job description
○ Procedure manual
Administrative Records with
Educational Value
The client record should describe the
client’s ongoing status and reflect the
full range of the nursing process,
regardless of the record system used in
an agency. So nurses document
evidence of the nursing process in a
variety of forms throughout the clinical
report
Documenting Nursing Activities
allow you to quickly
and easily enter assessment data
about a patient
○ It helps team members quickly
see patient trends over time and
decrease time spent on writing
narrative notes
Flow Sheets and Graphic Records
Body temperature, pulse,
respiratory rate, blood pressure,
weight, other significant clinical
data such as admission or
postoperative day bowel
movements, appetite and activity
Graphic Records
All routes measured and recorded
● Intake and Output
Date of order, expiration date,
name and dose, frequency and
route of administration, nurse’s
signature
○ some records also include a place
to document the client’s allergies
Medication administration record
Concise method of organizing and
recording data making information
quickly accessible to all health
professionals
Kardex
joint Commission requires clinical record
to include:
● Evidence of client assessment
● Nursing diagnosis
● Nursing interventions
● Client outcomes
● Current nursing care plans
Nursing Care Plan
Written for each client
○ The form varies from agency to
agency according to the needs of
the client and the department. So
most forms have three columns,
one for the nursing diagnosis,
second for expected outcomes,
and third for nursing
interventions.
Traditional Care Plan
Based on institutions standards of
practice
○ Developed to save documentation
time, so these plans may be
based on an institution’s
standards of practice, thereby
helping to provide high quality
nursing care for the patient. So
standardized plans must be
individualized by the nurse in
order to adequately address
individual clients needs.
Standardized care plans
Completed when client discharged
○ Terms that can be readily
○ Understood
● Completed when client transferred to
another institution to a home setting
where a visit by a community health
nurse is required.
Discharge Summary Forms
So if the client is being transferred to
another institution or to a home setting
where a visit by a home health nurse is
required. So the discharge note
takes
the form of a referral summary
