foundations week 4 documentation

chart or medical record is

the legal record of care

it is permanent confidential and admissible in court

only providers in direct care of patient have access to that record

true

what is documentation?

• anything that is written printed on which you rely as a record of proof of patient actions and activities

• wasn’t written then it wasn’t done mist document

purpose of record of medical health records

• interprofessional team to communicate about the client such as needs and response to treatment or clinical decisions process, education discharge planning etc

• provides legal record of care

• provides justification for financial billing and reimbursement of care

• support process of needed for quality and performance improvement

within medical records

• legal responsibility: documentation should be clear accurate and mistakes can highlight ,malpractice

• reimbursement: the quality of care provided

• auditing and monitoring the join commission and CMS requires it

• education: reading the chart identify trends patterns

• research: EBP

electronic documentation

EHRS (electronic health record system)

American recovery and reinvestment act

health information technology for economic and clinical health act

EHR(electroninc health record)

individuals lifetime

EMR(Electroninc medical record)

individual care visit

EMR(electroonic medication record)

for medication

advantage of electronic documentation

always available

can be done remote

multiple providers multiple can have access to it mor people look at. integrate information into one record

you can track who has had access to the chart

multiple people can see the visits wherever u go

legibilty easier to read since handwriting can understand

disasgnavtegs of thi electronic

can get hacked they get fined

easy access to nosy staff

visitors can sneak a peak

maintaining confidentiality and security

• nurses are obligated to keep all client information confidential

• nurses are responsible for protecting records from all unauthorized readers

• HIPAA requires that disclosure or request regarding health information are limited to the minimum necessary (only those involved in care can see can’t talk about care with anyone not involved)

HIPAA

Health insurance portability and accountability act

as a student regarding data

be careful of how u collect and transport data

deidentify(not have p.t identifiers on paper works such as DOB name social security)

don’t print anything(shred it)

Standrads

know Ur organization standards they vary

current documentation standards require that each patient have an assessment

physical psychosocial, environmental self-care, patient, education, knowledge level, discharge planning needs

nursing documentation standards are set by federal state regulations, state statutes , standards of care and accreditation agencies

FACTUAL-objective, its clear ;no it appear or it seems

ACCUARTE-exact numbers , measurements, clear no driannage not sweleing, 5/10 pain

APPROPRAITE ABBREVIATIONS: no trailing zeros
current : timely

organized : must follow DAR

complete

Legal guidelines

begin with time and date end with signature title

correct all errors using correct method: crossing out and put you name

record all facts; don’t enter personal opinions

don’t leave blank spaces on nurse notes

write legibly using blue or black ink

if ordered was questions wriet down that clarification was seeked out

chart only for yourself not for others

never pre document

keep you computer password safe

information inadvertently omitted may be added late

methods of documentation

paper record

electronic health record

paper record

• usually used if computer hacked, disaster or system goes down

• episode oriented

• key info may be lost form one episode of care to the next

electronic health record

• digital version of a p.t medical record

• integrates all of a p.t information in one record

• improves continuity of care

• used the most if not all

methods of documentation

• check box for assessment findings: you are going to check s1 normal not normal example

• by exception(within defined limits must be defined) it depends on faculty so tricky u cant select if not found

• narrative(progress notes, nurse notes, consultants anything that isnt in the check box

• forms of narratice notes

• SOAP/SOAPIE

• PIE

• AIO

• Focus charting (DAR)

SOAP

subjective objective assessment plan

SOAPIE

Subjective

objective

assessment

plan

intervention

evaluation

PIE

problem

intervention

evaluation

AIO

assessment

intervention

outcome

DAR

Data

action

response

common record keeping froms in EHR

• admission history form

• flow sheet and graphic records

• patient care and summary

• care plans

• discharge summary forms

DAR documentation

data:

this is the data you collect prior to doing the procedure

tell us why p.t needs this intervention

Action/Nursing intervention:

what did u do for the p.t and what happened during the procedure?

response of p.t:

how is p.t now and revaluate

very factual and patient centered what happened to the p.t

hand off report

occurs with transfer of p.t care

provide continuity and individualized care

reports are quick and efficient (SBAR)

telephone report and orders

• SBAR

• document every call even if no new orders received

• read back

• protects you* if u document u contact provider and no order was recived

• write date and wriet orders with that t.o or telephone order vo order read back to get the point across it was verbal or telephone read back orders and document

• your name and credential and the name of the physician in 24 hrs must be signed

incident or occurrence reports

• used to document any event that is not consistent with the routine operation of health care unit or the routine care of a p.t

• follow agency policy

• anything that occurred not in p.t chart

Electronic basics

• analysis can retrace every step u take in medical record you can correct mistakes but orignal entry will be accessible

• only access p.t whom you are caring fro or assiting care for

• LOGG OFF

• don’t share passcode

hourly rounding

pain

potty

positioning

• comfort level we look at skin the toileting

• periphery

• pump

• possession

• plan

• parting words

hourly expectations

• introduce explain why you are there, your skill set experience and others

• perform scheduled tasks

• address 3 ps pain potty position

• address additional comfort needs

• conduct environmental assessment

• using closing words and actions

• explain when you will be back or someone else would be back

• document the round on the chart

not super specific in time

• you can wait and document all visits at once but better to do to as u round

• you can change the time but it shows when u documented

• yes document in p.t room

• don’t use gloves on the computer unless isolation room

• yes document hourly rounding on sleeping p.t

health informatics

• application of computer and information science for managing health related data

• focus on p.t and the process of care

• role in nurse by developing system recommendation on it goal to enhance the quality and efficiency of the care provided

• driven by HITECH

• HITECH

health information technology for economic and clinical health act

clinical information systems

a hospital information system that consists of two major types of information systems such as CIS and CPOE

CIS

clinical information system

CIS definition

used to access p.t data such as vital signs assessments , orders, notes laboratory, radiology, and pharmacy systems

CPOE def

• HCPs directly enter standardizes legible and complete orders

• improves accuracy

• speeds implementation

• improves productivity

• saves money

CPOE

computerized provider order entry

nursing informatics

• a specialty that integrates nursing science computer science and information science to manage and communicate data, information knowledge in nursing practice

• supports the way that nurses function and work

• supports and enhances nursing practice through improved access to information and clinical decision making tools

NIS

nursing information systems

advantages of NIS

• increase time to spend with p.t

• better access to information

• enhanced quality of documentation

• reduced errs of omission

• reduced hospital costs

• increased nurse job satisfaction

• compliance with accrediting agencies

• common clinical database development

nursing p.t systems info

Privacy, confidentiality, and security mechanisms

 Legal risks

 Handling and disposal of information

 Protection of the confidentiality of patients’ health

information and the security of computer systems

 log-in processes

 audit trails

 Firewalls

 data recovery processes

 policies about handling and disposing of data to protect

patient information

HC record facilitates interprofessional communication

• Quality documentation

• Factual

• Accurate

• Appropriate Abbreviations

• Complete

• Current

• Organized

• Complete

Nursing documentation is essential

Communicates care provided

• Serves as legal record of care (limits liability)

• Supports reimbursement

• Access must be restricted & monitored

• Nursing students must develop KSAs that enable them to use

information & technology

When documenting a phone call with a provider, include:

1. Date and time of the call

2. Name of the provider

3. Reason for the call

   • Patient condition, concern, or change in status

4. Information reported

   • Assessment data, vital signs, symptoms

5. Orders received

   • Or document “no new orders received”

6. Read-back verification

   • Document that orders were read back and verified

7. Actions taken

   • Medications given, interventions started

8. Patient response

   • How the patient responded to the intervention

9. Your name and title

Quality documentation must be:

• Factual

• Accurate

• Appropriate abbreviations only

• Complete

• Current

• Organized

Documentation must meet legal standards to protect the patient, nurse, and facility.

Legal Documentation Rules

• Begin each entry with date and time

• End each entry with signature and professional title

• Correct errors promptly

  • Use the correct method (never erase or delete)

• Document facts only

  • No opinions, assumptions, or blaming language

• Do NOT leave blank spaces

• Write legibly (paper charting) in black or blue ink

• Chart only for yourself

  • Never document for another nurse

• Never pre-document

  • Chart only what has already occurred

• If an order is questioned, document that clarification was sought

• Late entries are allowed

  • Clearly labeled as a late entry

• Keep passwords secure

• Access only records of patients you are caring for

watch out

📌 Legal red flags on exams

• Pre-charting

• Altering records

• Sharing passwords

• Documenting opinions

Purpose of the Health Care Record

The health care record:

• Facilitates interprofessional communication

  • Allows nurses, providers, and the health care team to share patient information

• Provides a legal record of care

  • Proof of what care was provided and when

• Supports billing and reimbursement

  • Justifies charges (e.g., DRGs – Diagnosis Related Groups)

• Supports quality improvement

  • Used for auditing, monitoring, and performance improvement

• Serves as a resource for education and research

  • Helps improve evidence-based practice