Chapter 26 Informations and Documentations

Documentation

A key communication strategy that produces a written account of pertinent patient data, clinical decisions and interventions, and patient responses in a health record.

Document all nursing care provided:

• Patient assessment

• Nursing diagnoses

• Nursing interventions

• Patient response (evaluation)

Purpose of the health care record

• Communication

• Legal record

• Reimbursement

• Auditing and monitoring care

• Education and research

HITECH: Health Information Technology for Economic and Clinical Health Act

This is to improve patient safety. To decrease cost and to improve the quality of care that is given.

EHR v.s EMR

• EHR: Life long health record

• EMR: Individual vists

Quesions to ask related to privacy, confidentiality and security

• Nurse responsibility?

• What and with who can you discuss?

• What is protected?

• Use data for research or continuing education

Handling & Disposing of information

The nurse must safeguard any information that is printed from the record or extracted for report purposes. Destroy these documents when no longer in use, de-identify all of the patient data and use special considerations for faxing.

Standard and Guideline for Quality Nursing Documentation

Every nurse is responsible for understanding there own organizations policy on document. Most organizations will usually incorporate accreditation standards into there policies, ie: Nation Committee for Quality Assurance & TJC

Guidelines for Quality Documentation

• Factual

• Accurate

• Appropriate use of Abbreviations

• Current

• Organized

• Complete

Documentation of Assessment data

• A type of documentation method

• Flow sheet

• Progress notes

• Charting by exception: all standards for normal assessment finding or for routine care activities are met unless otherwise documented.

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

Documentation in the long-term health care setting

• Who dictates what is documented?

• What forms may be used?

• Why have quality documentation?

  • Adherence to care requirements

  • Reimbursement

  • Proof of care

Case management and use of critical pathways

• Case management model incorporates an interprofessional approach to delivery and documentation of patient care

• Critical Pathways: are interprofessional care plans that identify patient

  problems, key interventions, and expected outcomes within an established time frame 

• Variances: Unexpected outcomes and interventions not specified within a critical pathway 

Health information technology (HIT)

This is the use of information systems and other information technology to record, monitor, and deliver patient care, and to perform managerial and organizational functions in health care 

Health care information system (HIS)

Consists of “computer hardware and software dedicated to the collection, storage, processing, retrieval, and communication of patient care information in a healthcare agency” 

Clinical information system (CIS)

Also known as a patient care information system this is a large, computerized database management system that is used to access patient data needed to plan, implement, and evaluate care 

Nursing clinical information system (NCIS)

Incorporates the principles of nursing informatics to support the work that nurses do by facilitating documentation of nursing process activities and offering resources for managing nursing care delivery. 

Clinical decision support system (CDSS) 

This is a computer program that aids and supports clinical decision making. 

Nursing Informatics

This is the specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing and informatics practice