Foundations of Nursing - Documentation and Communication

Medical Record

All information about patients written on paper, spoken aloud, or saved on a computer.

Health Insurance Portability and Accountability Act (HIPAA) of 1996

A law that requires patient authorization for releasing health information for purposes other than treatment, payment, and routine health care operations.

Exceptions to HIPAA Authorization

Public Health Activities, Law Enforcement, Deceased Individuals.

HITECH Act of 2009

An act that promotes the meaningful use of health information technology and strengthens HIPAA rules.

Goal of HITECH Act

To improve quality, safety, and efficiency through information sharing and protect patient privacy and security.

Penalties under HITECH Act

Penalties for data breaches and required notification of patients if there is a breach.

Patient Rights under HIPAA

Patients have the right to see and copy their health records, choose how to receive this copy, update their chart, and obtain a list of disclosures.

Confidential Information

Information that should not be disclosed publicly, including patient health information.

Potential Breaches in Confidentiality

Actions that could lead to unauthorized disclosure of patient information.

Incidental Disclosure

A secondary disclosure of PHI that cannot reasonably be prevented and occurs as a by-product of an otherwise permitted use or disclosure.

Examples of Confidentiality Breaches

Displaying information on a public screen, sending confidential emails via public networks, and faxing confidential information to unauthorized persons.

Patient Information

Includes name, address, phone, fax, social security number, reason for illness, treatments received, and past health conditions.

Confidential Conversations

Holding conversations that can be overheard can lead to breaches of confidentiality.

Discarding Patient Information

Discarding copies of patient information in trash cans is a potential breach of confidentiality.

Sharing Printers

Sharing printers among units with differing functions can lead to breaches of confidentiality.

Transmitting Confidential Information

Transmitting any confidential information, including images, via social media is a breach of confidentiality.

Confidential Messages

Sending confidential messages that can be overheard on pagers is a breach of confidentiality.

Who Uses the Medical Record?

Healthcare providers and institutions that require access to patient information for treatment and care. Regulatory agencies, insurance companies, researchers, patient.

Incidental Disclosures

Examples include sign-in sheets, placing patient charts outside of exam rooms, white boards, calling out names in waiting room, and leaving appointment reminder voicemails.

HIPAA Violation

Occurs when any of the 18 identifiers specified by HIPAA are shared in a post, picture, or video without explicit, written consent from the patient.

Patient Identifiers

Obvious identifiers include patient name and date of birth; not obvious identifiers include vehicle identifiers, device serial numbers, and full-face photographic images.

Consequences of HIPAA Violations

Job termination, fines up to $50,000 per violation, and loss of nursing license or certification.

Best Practices for Social Media

Never post patient information, avoid discussing workplace incidents, and follow social media policies.

Patient Privacy Violation

A violation occurs if enough information is shared to reasonably identify the patient, regardless of whether the patient's name is used.

Social Media Policies

Guidelines that healthcare professionals must follow to avoid violating HIPAA and maintain professionalism.

Full De-identification

The process of removing all identifiable information from patient images or stories before sharing.

Who decides what to chart and what format?

Professional standards, health care personnel, governmental agencies, accrediting bodies

All documentation must be...

Complete

Concise

Timely

Accurate

Factual "unless" quotes the pt stated "..."

Secure

Confidential

Legally sound and meet established standards

Record observations, not interpretations

Document what is seen or heard, not personal opinions or interpretations.

Avoid generalizations

Do not use vague terms like 'tolerated well' or subjective words like 'good' or 'normal.'

Chronological order

Document assessments and interventions in the order they occur.

Document both treatments and failure to treat

Record all actions taken as well as any treatments that were not administered.

Timely Manner

Document as soon as possible, especially if something was forgotten.

Document nursing interventions

Record interventions as closely as possible to the time they are executed.

Never document interventions before carrying them out

Ensure that documentation reflects actions that have already been completed.

When do we chart?

Chart upon admission, transfer, discharge, shift assessment, procedure performance, and any change in patient status.

Write legibly

All entries must be clear and readable, using dark black ink.

Never skip lines

Ensure that each line of documentation is filled out completely.

Sign your name to each entry

Include your first initial, last name, and title with each entry.

Documentation failures in malpractice cases

20% of malpractice cases in the US show documentation failures.

Correcting Errors

Follow the correct protocol of your institution for correcting errors.

Computer charting errors

Correcting depends on the EMR system being used; consult with your facility's policy and procedures.

Confidentiality Guidelines

Patients have an ethical and legal right to health privacy.

Public area document handling

All documents in a public area should have a cover over them; information on white boards should be kept to a minimum.

Computer access information

Never give out your computer access information or let others utilize the computer under your screen name.

Narrative Notes

Nurse describes in their own terms the patient's assessment, interventions, and response; time-consuming and difficult to read.

Charting by exception

Guidelines define specific and concise 'normal assessments and expected outcomes'; narrative charting is done only on abnormal findings.

SOAP Notes

A structured method for documenting patient information. Subjective, Objective, Assessment, Plan

Abbreviations guidelines

TJC and ISMP provide guidelines for acceptable abbreviations, acronyms, symbols, and dose designations.

Medication documentation highlights

Spell out Units (NOT u or U), Spell out Daily (NOT QD), No trailing zero (NOT 1.0 mg, just 1 mg), Always use leading zero (0.1 mg).

Results of poor charting

Can lead to miscommunication and potential harm to patients.

Charting Medical Errors

Exact details should always be included in the chart; notification of patient and family completed and charted.

Incident report

Used to document an occurrence out of the ordinary that could or has caused patient harm; utilized for quality improvement.

Patient rights regarding health record

A patient has the right to obtain and review, but not revise the patient information in his or her health record.

What are the results of poor charting?

Lower the quality of patient care. Reflect poorly on the individual and nursing profession. Legal issues

What makes charting so difficult?

Computer issues. Interruptions. Prioritizing patient needs versus documentation.

How should an RN document verbal and telephone orders?

Write it out, read it back, not the modality (phone or verbal), write the full name of physician, sign or e-sign the orders with name and title and "read back".

Purpose of creating a patient record

To evaluate the quality of care patients have received and the competence of the nurses providing that care.

Patient safety

The prevention of errors and adverse effects to patients associated with healthcare.

Sentinel events

Unexpected events in healthcare that result in death or serious physical or psychological injury. Lack of/failure in communication, lack of teamwork, not following policies.

Intrapersonal communication

Internal communication that occurs within an individual.

Interpersonal communication

Communication that occurs between two or more individuals or groups.

Verbal communication

Communication that involves what is said and how it is said.

Nonverbal communication

Communication that includes body language, such as eyes, posture, and positioning.

Open communication

Communication that encourages elaboration with questions like what, when, how, and tell me more.

Closed communication

Communication that typically involves yes/no questions or statements like do/did/does.

Factors influencing communication

Developmental level, Sociocultural differences, Use of medical terminology, Lack of role clarity, Fear/insecurity, Pain, LOC/alertness

Active listening

Fully concentrating, understanding, responding, and remembering what is being said.

Effective communication

Communication that includes active listening, eye contact, tone of voice, facial expressions, noise, distractions, privacy, barriers, timing, location, and minimizing distractions.

Setting the Stage

An approach to communication that includes sitting facing the client, open posture, leaning in, maintaining eye contact, and relaxed posture.

Therapeutic communication

Communication that involves compassion, caring, empathy, and no judgment.

Collaborative communication

Communication that acknowledges visitors, does not assume relationships, and addresses both patient and family.

Communicating to Educate

The process of providing information to patients for informed decision making, including assessing current knowledge and breaking information into smaller sections.

TEACH BACK

A method to confirm patient understanding by asking them to repeat back the information provided.

ISBAR

A communication method that stands for Introduction, Situation, Background, Assessment, and Recommendation.

Nurse-to-Nurse Handoff

The transfer of patient care information from one nurse to another, which occurs during shifts or transfers.

Safe Handoff Components

Key elements to include during a handoff, such as name, age, medical history, admission diagnosis, and physical assessment findings.

Legal ramifications

The potential legal consequences resulting from actions or failures in communication within healthcare.

Ethical responsibility

The obligation to act in the best interest of patients and uphold ethical standards in communication.