Foundations Exam 4 (Informatics & Documentation)

Purposes of the Health Care Record

- valuable source of data for all members of the healthcare team

- Facilitates interprofessional communication (needs, treatment, consults, etc)

- Provides a legal record of care (accurate documentation is your best defense in legal situations; mistakes in documentation can result in malpractice)

- Provides justification for financial billing and reimbursement of care (quality of care provided to determine payment/reimbursement)

- Supports the process of needed for quality and performance improvement

- Serves as a resources for education and research

if it was not ________ then it was not done!

- If it was not documented, then it was not done

- keeps us accountable for the care we provide

- maintain confidentiality at all times

Interprofessional Communication Within the Medical Record

- Legal Responsibilities

- Reimbursement (Diagnosis Related Groups DRGs)

- Auditing & Monitoring

- TJC & CMS

- Education

- Research

EHRS

Electronic health record system (EHRS)

Advantages and Disadvantages

Advantage:

Allows you to see who has accessed the chart, gives access to charts remotely or for multiple physicians to access simultaneously. Also, more legible than paper charting.

Disadvantage: Record can get hacked

Fines associated w/ that

Easy access for nosy staff

Easy to access discreetly (but access can be tracked)

ARRA

American Recovery and Reinvestment Act (ARRA)

*Shift to electronic documentation began w/ ARRA in 2009

HITECH

Health Information Technology for Economic & Clinical Health Act (HITECH)

EHR

Electronic health record (EHR)

An individual's lifetime computerized record

EMR

Electronic medical record (EMR)

The record for an individual health care visit

EMR (medication)

Electronic medication record (EMR)

The record medication administration

Maintaining Confidentiality and Security

- Nurses are legally and ethically obligated to keep all client information confidential.

- Nurses are responsible for protecting records from all unauthorized readers.

- Don’t share passwords * log off * never leave visible

HIPAA

Health Insurance Portability and Accountability Act

HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary.

Standards

Current documentation standards require that each patient have an assessment:

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

- Nursing documentation standards are set by federal and state regulations, state statutes, standards of care, and accreditation agencies.

Legal Guidelines of Recording

- Begin each entry with the date/time and end with your signature and title

- Correct all errors promptly, using the correct method.

- Record all facts; do not enter personal opinions.

- Do not leave blank spaces in nurses' notes.

- Write legibly in permanent black (blue) ink.

- If an order was questioned, record that clarification was sought.

- Chart only for yourself, not for others.

- Never Pre Document.

- Keep your computer password secure.

- Information inadvertently omitted may be added as a late entry

Guidelines for Quality Documentation and Reporting

Factual

Accurate

Complete

Current

Organized

Appropriate abbreviations

paper record

episode-oriented

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

used during electronic downtime

EHR improves ________ of care

digital version of a pt medical record that integrates all pt information in one record; improves continuity of care

Methods of Documentation

- Check box for assessment findings

- By exception (within defined limits...must be defined)

- Narrative (Progress Notes, Nurses Notes, Consultations)

- SOAP/SOAPIE

- PIE (problem, intervention, evaluation)

- Problem, Intervention, Evaluation

- Assessment, Intervention, Outcome (AIO)

- Focus charting (DAR)

PIE

problem, intervention, evaluation

SOAP/SOAPIE

Subjective, Objective, Assessment, Plan (Intervention, Evaluation)

DAR

Data

Action

Response

AIO

Assessment

Intervention

Outcome

Common Record Keeping Forms in EHR

-Admission History Form

-Flow Sheet & Graphic records: visual source of data; trends; ex. graph of BP measurements

- Patient Care Summary: all the pt information in one page

- Care Plans

- Discharge Summary Forms: starts as soon as pt is admitted

DAR Documentation

**Factual & patient centered**

Data: What is going on?

This is the data you collect prior to doing the procedure

Tell us why patient needs this intervention

Action/Nursing Intervention:

What did you do for the patient, and what happened during the procedure

Response of the Patient:

How is the patient now? Re-evaluate/follow up

When charting..

- use blue/black ink only

- write legibly

- cross out errors w/ single line and your name

- do not skip lines

- when computerized, you can change time stamp but there is an underlying mark that indicates when the original note was written SO make sure you're documenting as close to the time of the event as possible.

Scenario:

Pt. w/ headache and no pain meds ordered

1) Background: what do you usually take, do you get frequent headaches, ck pt chart for vital signs and allergies

2) PQRST

3) Call the MD. Hae the chart available (know labs, meds, allergies)

4) Use ISBAR to get the order

5) READ IT BACK make sure you have all the right info (dosage, freq, spelling of MD)

6) Transcribe the order: date/time, exact order, TORB MD Name/your name and credentials

Patient-focused charting

Describe what happened to the patient (do not use I statements)

Examples:

- Pt educated regarding need to use call light

- 16F foley catheter inserted w/ sterile technique

Documenting Communication

Hand-off report

- Occurs with transfer of patient care

- Provides continuity and individualized care

- Reports are quick and efficient (SBAR)

Telephone reports and orders

- Situation-Background-Assessment-Recommendation (SBAR)

- Document every call…even if no new orders received

- Read back

Incident or occurrence reports

- Used internally, not part of pt record

- Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient

- Follow agency policy

EMR Basics

- Analysts can retrace every step you take within the patient's medical record

- You can correct your mistakes, but your original entry will still be accessible

- Only access patient's whom you are caring for or assisting to provide care for

- LOG OFF!!!

- Do not share your password...ever!

Hourly Rounding (the Ps)

pain, potty, positioning

periphery, pump, possessions, plan, parting

Example of Hourly Rounding

1. use opening words and/or actions to introduce yourself, your skill set, and your experience

2. perform scheduled tasks

3. address the 3 Ps of pain, potty, positioning

4. assess additional comfort needs

5. conduct environmental assessment

6. use closing key words and/or actions

7. explain when you or others will return

8. document the round on the log/chart.

Documenting Hourly Rounds

- Can I wait to document all visits at once? Document right as you perform the care. You can go back and add them in but it is better to have it documented as it's done.

- Are the entries time stamped? Yes.

- Can I change the time? Yes, but the original time stamp will still be accessible.

- Should I document in the patient’s room? Yes, you can. Even if my back is to the patient? Yes, gives you a chance to ask if they have questions while you are charting.

- To glove or not to glove??? Pt. not on isolation do not use gloves on the computer (yes to gloves if on isolation)

- Can I document an hourly check on a sleeping patient? Yes. Do not need to wake up pt, you can select the box that says pt. is sleeping.

- Should I wake him/her? Do not need to wake them for evening hourly rounds unless necessary.

Health Informatics

- Application of computer and information science for managing health-related data

- Focus on the patient and the process of care

- Role of nurses?

- Goal is to enhance the quality and efficiency of care provided.

- Driven by the Health Information Technology for Economic and Clinical Health Act (HITECH)

Clinical Information Systems

A hospital information system consists of two major types of information systems:

Clinical Information Systems (CIS)

Computerized provider order entry (CPOE)

CIS

Clinical Information System (CIS)

Used to access patient data such as vital signs, assessments, orders, notes, laboratory, radiology, and pharmacy systems

CPOE

Computerized provider order entry

HCPs directly enter standardized, legible and complete orders.

- Improves accuracy

- Speeds implementation

- Improves productivity

- Saves money

Nursing Informatics

- A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and 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

Advantages of Nursing Information Systems

Increased time to spend with patients

Better access to information

Enhanced quality of documentation

Reduced errors of omission

Reduced hospital costs

Increased nurse job satisfaction

Compliance with accrediting agencies

Common clinical database development

NIS

nursing information systems

Nursing Information Systems (cont'd)

- Privacy, confidentiality, and security mechanisms

- Legal risks (make sure you log off)

- 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 (shred pt info)

Key Points

•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