OTHER SOURCES OF CLIENT DATA Flashcards
OTHER SOURCES OF DATA
- PRIMARY SOURCE OF DATA
- SECONDARY SOURCES OF DATA
- medical information held about an individual patient.
- include information relating to their past and current health or illness, their treatment history, lifestyle choices
and genetic data.
CLIENT’S DATA
the PATIENT is the primary source of data collection in health assessment
PRIMARY SOURCE OF DATA
data include information from the patient’s chart, family members, or other health care team members
SECONDARY SOURCES OF DATA
*Several terms are used interchangeably to describe a patient’s medical chart, including medical records, health
records, and patient/client charts.
* is a complete and total record of a patient’s clinical data and medical history
* All refer to a private medical record that contains systematic documentation of an individual patient’s
important clinical data and medical history over time.
* Typically, patient charts include vitals, medications, treatment plans, allergies, immunizations, test results,
patient demographics, diagnoses, progress notes, and reports.
* All information in patient charts comes from nurses, lab technicians, physicians, and other practitioners
involved in the patient’s care
* Patient medical charts display a patient’s key medical information so practitioners can make more accurate
diagnoses and develop treatment plans with better outcomes.
CLIENT’S CHART
“Requires client record to be timely, complete, accurate, confidential and specific to the client.”
According to JCAHO
* The Joint Commission (formerly known as Joint Commission on Accreditation of Healthcare Organization) is
the peer review organization which provides the primary review of hospitals and healthcare providers.
“ . . . the nurse has a duty to maintain confidentiality of all patient information.”
According to ANA Code of Ethics
* The American Nurses Association Code of Ethics was developed as a guide for carrying out nursing
responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.
“Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing
accountability.”
- According to Code of Ethics for Filipino Nurses
* The Code of Ethics for Filipino Nurses outlines ethical principles and guidelines for registered nurses in their
interactions with people, practice, co-workers, society, environment, and the nursing profession.
requires the creation of
national standards to protect sensitive patient health information from being disclosed.
- According to HIPAA
* The Health Insurance Portability and Accountability Act of 1996 is a federal law that
- Ensuring confidentiality of computer records:
*Personal password that is not to be shared
* Never leave a computer terminal unattended after logging on
* Do not leave client information displayed on the monitor where others may see it
* Shred all unneeded computer-generated worksheets
* Know facility’s policy and procedure for correcting an entry error
* Follow agency procedures for documenting sensitive material
* IT personnel must install a firewall to protect server from unauthorized access
- In general . . . .
- Confidentiality and privacy of all patient information is needed.
- Client’s record protected legally as a private record of client’s care
- Responsibility in using records for the purpose of education and research
The primary purpose of the ______________ is to provide continuity of care which means documenting services, so others
have a source upon which to base care
patient record
PURPOSES OF CLLIENT RECORDS
- Communication
- Planning Client Care
- Auditing Health Agencies
- Research
- Education
- Legal Document
- Health Care Analysis
Prevents fragmentation, repetition and delays in client care as it is used by health care professionals
in communicated with each other and with the client.
Communication
Client records are kept for several purposes, including communication, planning client care,
auditing health agencies, research, education, reimbursement, legal documentation, and health care analysis.
Planning Client Care
Review client records for quality assurance to determine if the hospital is meeting its
stated standards
Auditing Health Agencies
Data in the record can be used for nursing research. Treatment plans for several clients with the same health
problems can yield information helpful in treating other clients.
Research
Client records may use data as educational tools
Education
Client’s records serve as evidence in court. Admissible in court as evidence unless client objects
because information client gives to primary care provider is confidential
Legal Document
Records may help health care planners identify agency needs, such as overuse or underuse of
hospital services.
Health Care Analysis
KEY ELEMENTS OF A CLIENT’S MEDICAL CHART
- Patient Demographics
- Financial Information
- Consent and Authorization Forms
- Medical History (Treatment)
- Nursing Records
- Diagnostic Procedures and Laboratory Results
- Operative and Anesthesiology Report
- Discharge Summary
- Filled out by the patient on their first visit to the doctor’s office and updated as needed.
- It contains information that is directly related to the patient, such as their last name, first name, gender, DOB,
marital status, address, telephone number, employment status, employer’s address and phone number, and
name and contact information for the person who is responsible for them.
- Patient Demographics
- Assignment of benefits: the patient or guarantor authorizes their health insurance company to make payments
directly to the physician, medical practice, or hospital for the treatment received. - Insurance information includes Insurance payer’s name, address, and phone number, Subscriber name, Policy
number, Responsible party name, address, and phone number, Responsible party employer, occupation, and
employer phone number Patient’s relationship with the insured.
- Financial Information
- This document outlines any medical ailments the patient has had in the past and present.
- A complete head-to-toe evaluation of the patient’s physical state is included in the physical examination (PE).
- Medical History includes: Chief Complaint, History of illness (present and past), vital signs, physical
examination, surgical history (for patients who had surgery), obstetric history (for pregnant women), allergies,
family history, immunization history (for pediatric clients), habits such as exercise, diet, sm
- Medical History (Treatment)
- It is a signed statement from the patient or guardian approving the course of treatment.
- For any course of treatment that is above routine medical procedures, the physician must disclose as much
information as possible so the patient may make an informed decision about his/her care. - Needs Consent/Authorization Forms: Diagnosis and chances of recovery. The recommended course of
treatment. - Things to be discussed before signing the forms: Risks and benefits involved in the treatment, Risks if no
treatment is taken, Probability of success if treatment is taken Recovery challenges and length of time. - Release of Information
Need to bring:
o A valid authorization to release protected health information. Identity verification such as a driver’s
license. A description of the information to be used or disclosed.
o The name of the person or organization authorized to disclose the information.
o The name of the person or organization authorized to disclose the information, and the information
is to disclose.
o An example of this are the birth certificates to be claimed and death certificated as well.
- Consent and Authorization Forms
o Physician’s orders for the patient to receive testing, procedures, or surgery including directions to other
treatment team members.
o Prescriptions for medications and medical supplies or equipment for the patient’s home use.
o Findings opinions from consulting physicians.
- Doctors Order Sheet
*In these records, vital indicators including blood pressure, temperature, pulse, respiration, intake, output, etc of
the patient are recorded.
* Nurse’s notes include documentation separate from the physician including Assessment, Nursing Diagnosis,
Planning, Intervention, & Evaluation.
- Nursing Records
Prescribed medication including dose, method of intake, and schedule
- Medication List
include new information and changes during patient treatment.
- Progress Notes
- Surgeon’s written account of the process, including the preoperative and postoperative diagnoses, the precise
specifics of the surgical procedure, the patient’s response to it, and any complications that may have arisen. - Information from the attending anesthesiologist or anesthetist that provides a thorough account of anesthesia
during surgery, including the drugs used, their dosage and administration time, the patient’s reaction, the
monitoring of vital signs, how well the patient tolerated the anesthesia, and any complications that may have
arisen
- Operative and Anesthesiology Report
- These comprise documents containing the findings of every diagnostic test and laboratory procedure that the
patient underwent. - The findings or outcomes of samples taken from the patient, such as bone marrow, blood, or tissue, are
documented in the pathology report. Record of findings from radiology testing, Ultrasound, ECG.
- Diagnostic Procedures and Laboratory Results
- A summary of the patient’s hospital care, including the date of admission, the diagnosis, the course of treatment
and any responses from the patient, the outcomes of the tests, the final diagnosis, the follow-up plans, and the
date of discharge.
- Discharge Summary
HOW TO KEEP GOOD NURSING RECORD
- Part of the nursing care we give to our patients.
- Without clear and accurate nursing records for each patient, endorsement to the next shift of nurses will be incomplete.
- The quality of record-keeping can be a good (or bad) reflection of the standard of care given to patients.
- Careful, neat, and accurate patient records are the hallmarks of a caring and responsible nurse, but poorly written records
can lead to doubts about the quality of a nurse’s work. - Nursing records are proof that you have fulfilled your duty of care to the patient,
- Poor record-keeping can mean negligence. even if provided the correct care - and this may cause you to lose your right
to practice.
- Ensure that records are accurate and complete to effectively manage the client and allow for good
communication between the nurse and other healthcare members. - Keeping
NURSE’S RESPONSIBILITY
COMMON RECORD KEEPING FORMS (Common forms used in the hospital)
- Admission Nursing Forms
- Flow Sheets and Graphic Records
- Kardex
- Nurses Progress Notes
- Discharge Summary Forms
- A nurse completes a nursing history form when a patient is admitted to a nursing unit.
- The form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems.
- Admission Nursing Forms
- Flow sheets 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
Graphic record
All routes measured and recorded.
Intake and output
- Date of order, expiration date, name and dose, frequency and route of
administration, nurse’s signature
Medication administration record
- Concise method of organizing and recording data
- Series of cards kept in a portable index file or on computer-generated form.
- Information quickly accessible
- Pertinent information about the client arranged in sections.
- Kardex
- Made by nurses.
- Provide information about the progress a client is making toward achieving desired outcomes.
- Include information about client problems and nursing interventions.
- Nurses Progress Notes
- Completed when client discharged - terms that can be readily understood.
- Completed when client transferred to another institution.
- Include some or all the following: Description of client’s physical, mental, and emotional status, resolved health problems, Treatments to be continued, Current medications, include restrictions that relate to activity, diet, and bathing, Functional/self-care abilities, Comfort level, Support networks, Client education, Discharge
destination, Referral services.
- Discharge Summary Forms
