week 9: Medical Records & Documentation Flashcards
define confidentiality and its purpose
the maintenance of privacy, by not sharing or divulging to a third party privileged or entrusted information
what is HIPPA? & what is the goal?
HIPAA is a measure to protect a patient’s health information while allowing the flow of health information needed to provide and promote high quality health care.
how do we properly handle and dispose of information?
-you must safeguard any information that is printed from the record or extracted for report purposes
-de-identify all patient data (ie. Use patient initials)
-special considerations for faxing
what is the EHR? example?
Electronic Healthcare Record
-a record of patient health information generated whenever a patient accesses medical care in any healthcare delivery setting
-ex: kaiser
what is the EMR? example?
Electronic Medical Record
-contains patient data gathered in a healthcare setting at a specific time and place and is part of the Healthcare Record
-ex: physcian’s office
what is the purpose of the record?
-communications
-legal documentation
-reimbursement
-education
-research
-auditing/monitoring
what is documentation?
the permanent medical legal record of a patient’s health status and treatment. It is a record or proof of the assessments, actions, and activities
when to document?
document in a timely manner all assessments and nursing interventions and patient activities throughout the shift
-has to be done before end of shift
guidelines for quality documentation
-factual (objective parameters)
-accurate (exact measurements)
-complete but concise
-current info
-organized
-short sentences but NO abbreviations
methods of documentation: narrative
-traditional
-story like format
-chronological time and/or by body system
methods of documentation: Charting by Exception (CBE)
-reduces documentation time
-if body system normal write “within normal limits”
-highlight changes in pt condition
problem-oriented documentation: SOAP, SOAPIE, SOAPIER
S=subjective
O=objective
A=assessment (interpret problem)
P=plan (plan of care)
I=intervention (nursing actions)
E=evaluation
R=revision (of plan)
problem-oriented documentation: PIE, APIE
A=assessment
P=problem
I=intervention
E=evaluation
problem-oriented documentation: FDAR
F=focus
D=data
A=action
R=response
Legal Guidelines Documentation: The Do Not’s
-blank spaces→put lines through
-felt tip pens →bleed through
-erasable ink or white out
-personal opinions
Legal Guidelines Documentation: The Do’s
-be descriptive (just the facts)
-legible in black in
-include (time, date, signature = first initial, last name, title)
what do you do if you make a documentation error?
-draw a single line through the error, write the word “error” above it
-sign your name or initials and date it
-then record the note correctly
proper documentation signature & example
first initial, last name, title
A. Moreno, USFSN
what is HITECH and purpose?
HITECH established provisions to promote the meaningful use of health information technology (HIT) to improve the quality and value of health care
-purpose: decrease costs and improve the quality of patient care
