Week 5 - Communication

documentation

• Key communication strategy

• Produces a written account of patient data, clinical intervention and patient responses

• Available to all members of the healthcare team

• Allows others to track a patient’s clinical course

purpose of health care record

• Facilitates interprofessional communication

• Provides a legal record of care

• Provides justification for financial billing and reimbursement of care

• Supports the process needed for quality and performance improvement

• Serves as a resources for education and research

interprofessional communication (within the medical record)

• Confidential - HIPAA

• Legal documentation

• Reimbursement

• Auditing and monitoring

• Education

• Research

electronic health record system (EHRS)

is the computer system used to store, manage, and access patients' electronic health records (software healthcare workers use to document patient care)

• Epic is an electronic health record system used in many hospitals.

• american recovery and reinvestment act (ARRA)

• health information technology for economic and clinical health act (HITECH)

electronic health record

is a digital record of a patient's health information over time that can support care across different healthcare settings.

It may include:

• Medical history

• Allergies

• Medications

• Lab results

• Diagnoses

• Immunizations

• Treatment plans

electronic medical record

is a digital patient record typically used within one healthcare organization or practice.

• It usually focuses on the care provided by that particular facility or provider.

protected health information (PHI)

encompasses past, present, or future physical or mental health conditions, healthcare services provided, and payment details linked to an individual

• Maintaining privacy, confidentiality, and security of the health care record

standards and guidelines for quality nursing documentation

guidelines for quality documentation

Guidelines for quality documentation

• Factual

• Accurate

• Appropriate use of abbreviations

• Current

• Organized

• Complete

documentation of patient assessment data

• Flow sheets

• Progress notes

• Charting by exception

common record keeping forms

within the electronic health record

• Admission nursing history form

• Patient care summary

• Care plans

• Discharge summary forms

documenting communication

with providers and unique events

• Telephone calls

• Telephone and verbal orders

• Incidence or occurrence reports

acuity rating system

Used to determine hours of care and number of staff required for a group of patients every shift or every 24 hours.

patients acuity level

Based on the type and number of nursing interventions required by that patient over a 24-hour period

documentation in the acute / long term care setting

Governed by

• Individual state regulations

• The Joint Commission (TJC)

• Centers for Medicare and Medicaid Services (CMS)

documentation in the home health care

• Medicare has specific guidelines to establish eligibility for home care reimbursement.

• Documentation is the quality control and the justification for reimbursement from Medicare, Medicaid, or private insurance companies.

• Nurses use two different data sets to document clinical assessments and care provided in the home care setting.

nursing documentation

• Accurate: Record correct information.

• Complete: Include all important patient information.

• Timely: Document as soon as possible after providing care.

• Objective: Record facts rather than personal opinions.

• Clear and concise: Use simple, understandable language.

• Organized: Document information in a logical order.

• Confidential: Protect the patient's private information.

ISBARR

is a structured communication tool nurses use to share important patient information clearly and efficiently.

• It is especially useful when contacting a provider or giving a patient handoff report.

• After communicating, document the significant information exchanged, the provider's response, verified orders, interventions, and follow-up assessment.

Introduction

(I) - Identify yourself, your role, and the patient

"Hello, this is Sarah, the RN caring for Mr. Jones in room 204."

Situation

(S) - Explain what is happening right now

"I'm calling because his blood pressure dropped to 85/50."

Background

(B) - Provide relevant patient history

"He was admitted for dehydration and has been experiencing vomiting."

Assessment

(A) - Explain your assessment findings

"He reports dizziness, and his heart rate is 115 beats/minute.”

Recommendation

(R) - State what you need or recommend

"I would like you to evaluate him and provide further orders."

Readback

(R) - Repeat and verify orders or critical information

"To confirm, you ordered 500 mL of normal saline IV over 30 minutes."

clinical judgement model

explains how nurses use patient information to make safe decisions about care.

1. recognize cues

2. analyze cues

3. prioritize hypotheses

4. generate solutions

5. take action

6. evaluate outcomes

recognize cues

Notice important patient information

analyze cues

Understand what the findings mean

prioritize hypotheses

Identify the most urgent problem

generate solutions

Plan possible nursing interventions

take action

Perform the appropriate interventions

evaluate outcomes

Determine whether the interventions worked

clinical judgment example

1. Recognize cues: Patient has SpO₂ of 86%, shortness of breath, and rapid breathing.

2. Analyze cues: These findings suggest impaired oxygenation.

3. Prioritize hypotheses: The patient's breathing and oxygenation are the immediate priority.

4. Generate solutions: Consider positioning, oxygen according to orders/protocol, and further respiratory assessment.

5. Take action: Sit the patient upright, initiate appropriate interventions, and obtain urgent assistance as indicated.

6. Evaluate outcomes: Reassess oxygen saturation, respiratory effort, and the patient's condition.

HIPPA

Health Insurance Portability and Accountability Act of 1996

protects Protected Health Information (PHI), which includes identifiable health information such as:

• Patient names and birth dates

• Medical diagnoses

• Medical record numbers

• Lab results

• Medications

• Treatment information

• Billing information

HIPPA rules for nurses

1. maintain confidentiality

2. access only info needed to do job

3. protect electronic records

4. share information appropriately

5. follow the minimum necessary rule