Chapter 20 - Documenting, Reporting

Why is it important to document?

If you didn’t document it, it didn’t happen

What is documentation and what are the elements of documentation?

written or electronic legal record of all pertinent interactions w/ the patient

elements: ADPIE

What are the pt rights regarding their reports and documentation?

• see and copy their health record

• update private info

• get list of disclosures

• request restriction or certain uses or disclosures

• choose how to receive health info

What is a pt record? What is the purpose of pts records?

compilation of a pt’s health info

purpose:
- communication
- diagnostic + therapeutic orders
- care planning
- research
- education
- reimbursement
- legal and historical doc
- quality process/performance improvement
- regulation and legislation

What is HIPAA?

Health Insurance Portability and Accountability Act

Federal law passed in 1996 that protects patient medical privacy, ensures health insurance job portability, and sets rules for data security

What pt info should be confidential?

• name, address, phone, fax, SSN

• reason pt is sick

• tx

• info about past hx

What are some potential breaches of pt confidentiality?

• info on public screen

• e-mails

• sharing printers among units

• discarding pt info in trash

• holding convos that can be overheard

• faxing info to unauthorized persons

How should a nurse handle a verbal or telephone report from another provider?

record verbal order + document name of physician issuing the order, nurse’s name/initials, time/date, signature

also read the order back to them

What are the benefits of using an electronic health record?

• provides accurate, up to date info

• quick access

• more secure sharing

• catches mistakes

• less paperwork

What are some ways to safely chart on a computer?

• don’t share personal password

• don’t leave computer unattended when logged in

• correct errors

• don’t create/change/delete records unless authorized to do so

• follow confidentiality procedures