Technology/Informatics (Class 19)

Well... I tried.

True

True

True or False: If it’s not documented, it’s not done.

Purpose of Healthcare Record/Documentation

• Resource for education and research.

• Facilitate interprofessional communication.

• Provide legal record of care.

• Justification for billing and reimbursement.

• Used to audit, monitor, and evaluate quality of care.

Health Information Technology

The process, storage, and exchange of health info in an electronic environment.

Legal Documentation

Accurate documentation is one of the best defenses for legal claims associated with nursing care.

Reimbursement

Accurate documentation of nursing services provided, as well as the supplies and equipment used in a patient’s care, clarifies the type of treatment a patient received, and supports accurate and timely reimbursement to a health care agency and/or patient.

Auditing and Monitoring

Offer info on recurrent healthcare problems, specific patient incidents, and whether healthcare providers follow standards of care. Identify areas for improvement and staff development.

Education

An effective way to learn the nature of patient’s condition and response to treatment.

Research

Analysis of the data contributes to evidence-based nursing practice and high-quality healthcare.

Electronic Health Record (EHR)

Refers to an individual’s lifetime record.

Electronic Medical Record (EMR)

Refers to an individual’s singular visit or admission.

Health Insurance Portability and Accountability Act (HIPAA)

Provides protection for patient records; governs all areas of patient health information and information management.

PHI

Individually identifiable health information transmitted by electronic media, maintained in electronic media, or transmitted/maintained in any other form or medium.

HIPAA Identifiers

1. Patient names

2. Geographical elements

3. Dates related to the health or identity of the individuals

4. Telephone numbers

5. Fax numbers

6. Email addresses

7. Social security numbers

8. Medical record numbers

9. Health insurance beneficiary numbers

10. Account numbers

11. Certificate/license numbers

12. Vehicle identifiers

13. IP addresses

14. Full face photographic images

True

True or False: Once printed client medical information is no longer necessary, de-identify the patient and destroy the information via a locked shredder.

Guidelines for Quality Nursing Documentation

• Factual

• Accurate

• Abbreviations

• Current

• Organized

• Complete

Factual

• Contains clear descriptive, objective info about what a nurse observes.

• Avoid vague phrasing

• Put a patient’s exact words in quotes for subjective info.

Accurate

• Using exact measurements establishes this and helps you determine whether a patient’s condition has changed.

• Avoid using unnecessary words and irrelevant detail.

Current

• Essential in a patient’s ongoing care as delays in documentation can lead to unsafe patient care.

• Document as SOON AS YOU COMPLETE A PROCEDURE.

False

True or False: Time in healthcare is managed using the 12-hour clock.

Organized

• Documentation is more effective when notes are concise, clear, to the point and presented in a logical order.

• Think about a situation, then more decisions about what info/words you need to include.

Complete

• Be sure info is containing all appropriate and essential info.

TJC’s “Do Not Use” List

Determines what abbreviations are safe and appropriate to use in documentation. Abbreviations are usually added if they are too similar to others or could easily be misconstrued.

Flow Sheet

Graphic records that are organized by body system and navigated using tabs and rows.

Progress Notes

Used to monitor and record the progress made toward resolving a patient’s problems.

Narrative Note

Consists of a story-like format to document info. Traditionally used for notes.

A-PIE

Assessment

Problem/Diagnosis

Interventions used to address problems

Evaluation of interventions

Focus (DAR)

Data

Action or Nursing intervention

Response of the patient

SOAP

Subjective

Objective

Assessment

Plan

Charting by Exception

All standards for normal assessment findings or for routine care activities are met unless otherwise documented.

TORB

Telephone Order, Read Back

Verbal Order

• Given face-to-face to a nurse

• Only used in times of emergency

Telephone Order

• Given over the phone

• Increasingly less common

Guidelines Used for Telephone or Verbal Orders

• Only authorized staff receive and record them.

• Clearly identify the patient’s name, room number, and diagnosis.

• Use clarification questions to avoid misunderstanding.

• Document TORB or VO after your signature

• Read back ALL orders.

• The healthcare provider must sign the order within 24 hours.

Mistakes in Documentation that Can Result in Malpractice

• Failing to record pertinent health or medication info

• Failing to record nursing actions

• Failing to record medication administration

• Failing to record medication reactions or changes in patients’ conditions

• Incomplete or illegible records

• Failing to document discontinued medications

HIPAA for Patients

• Patients can request a copy of their medical record.

• Patient must receive notification of privacy rights and disclosure.

• Patient must authorize release of information.

• Institution may use and disclose information for treatment, payment, and healthcare operations without authorizations.

• Use of data in research requires deidentification or patient authorization.

• Request a restriction on certain uses or disclosures.

HIPAA for Healthcare Providers

• Gives patients more control over their health information.

• Sets boundaries on the use and release of health records.

• Establishes safeguards that healthcare providers and others must achieve to protect the privacy of health information.

• Holds violators accountable with civil (monetary fine) and criminal (imprisonment) penalties.

Confidentiality

• Nurses are legally and ethically obligated to keep information about patients confidential.

• Only members of the healthcare team who are directly involved in a patient’s care have legitimate access to a patient’s health record.

• You discuss a patient’s diagnosis, treatment, assessment, and any personal conversations only with members of the healthcare team who are specifically involved in the patient’s care.

• Do not share information with other patients or with healthcare team members who are not caring for the patient.

Incident/Occurrence Report

Completed whenever an incident occurs. Analysis of them helps the identify system and/or individual human issues in which educational or in-service programs or changes in policies/procedures are needed to reduce the risk of future occurrences.

Examples of Incidents

• Patient falls

• Needlestick injuries

• Medication administration errors

• Accidental omission of ordered therapies

• A visitor needing medical attention

• Near misses

False

True or False: You should mention and record the incident or occurrence in the client’s progress note.

Critical Pathway

Interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame. Facilitate integration of care because all team members use one document.

Health Information System

Consists of computer hardware/software dedicated to the connection, storage, and processing/retrieval of patient care into a healthcare agency.

Clinical Information System

Large, computerized database management system that is used to access patient data needed to plan, implement, and evaluate care. Includes monitoring systems; order entry systems, and laboratory/radiology/pharmacy systems.

Nurse Informatics

A specialty that integrates nursing science, computer science, and informational science to manage and communicate data in nursing and informatics practice.