week 9: Medical Records & Documentation

Question 1

define confidentiality and its purpose

Answer 1

the maintenance of privacy, by not sharing or divulging to a third party privileged or entrusted information

Question 2

what is HIPPA? & what is the goal?

Answer 2

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.

Question 3

how do we properly handle and dispose of information?

Answer 3

-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

Question 4

what is the EHR? example?

Answer 4

Electronic Healthcare Record
-a record of patient health information generated whenever a patient accesses medical care in any healthcare delivery setting
-ex: kaiser

Question 5

what is the EMR? example?

Answer 5

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

Question 6

what is the purpose of the record?

Answer 6

-communications
-legal documentation
-reimbursement
-education
-research
-auditing/monitoring

Question 7

what is documentation?

Answer 7

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

Question 8

when to document?

Answer 8

document in a timely manner all assessments and nursing interventions and patient activities throughout the shift
-has to be done before end of shift

Question 9

guidelines for quality documentation

Answer 9

-factual (objective parameters)
-accurate (exact measurements)
-complete but concise
-current info
-organized
-short sentences but NO abbreviations

Question 10

methods of documentation: narrative

Answer 10

-traditional
-story like format
-chronological time and/or by body system

Question 11

methods of documentation: Charting by Exception (CBE)

Answer 11

-reduces documentation time
-if body system normal write “within normal limits”
-highlight changes in pt condition

Question 12

problem-oriented documentation: SOAP, SOAPIE, SOAPIER

Answer 12

S=subjective
O=objective
A=assessment (interpret problem)
P=plan (plan of care)
I=intervention (nursing actions)
E=evaluation
R=revision (of plan)

Question 13

problem-oriented documentation: PIE, APIE

Answer 13

A=assessment
P=problem
I=intervention
E=evaluation

Question 14

problem-oriented documentation: FDAR

Answer 14

F=focus
D=data
A=action
R=response

Question 15

Legal Guidelines Documentation: The Do Not’s

Answer 15

-blank spaces→put lines through
-felt tip pens →bleed through
-erasable ink or white out
-personal opinions

Question 16

Legal Guidelines Documentation: The Do’s

Answer 16

-be descriptive (just the facts)
-legible in black in
-include (time, date, signature = first initial, last name, title)

Question 17

what do you do if you make a documentation error?

Answer 17

-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

Question 18

proper documentation signature & example

Answer 18

first initial, last name, title
A. Moreno, USFSN

Question 19

what is HITECH and purpose?

Answer 19

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