Documentation

Documentation and Informatics

• Health Care Record:

  • Legal record of all interactions with the patient.

  • Describes patient, health status, and provided services.

  • Includes relevant dates of care.

  • Patient records are compilations of patient health information (PHI).

Electronic Health Records (EHRs)

• Definition: Systematic digitized documentation to enhance client care.

• Features:

  • Comprehensive records of an individual’s health history.

  • Communication tool for all providers involved in the client's care.

  • Records every treatment, diagnosis, and visit for billing.

  • Components can be used in court.

• Advantages:

  • Improved efficiency in health care delivery.

• Disadvantages: Vulnerabilities to hacking.

Types of Documentation

• Focus on modern types including:

  • Source-oriented medical records:

  • Traditional format, divided into sections (e.g., history, notes, lab reports).

  • Problem-oriented medical records.

  • SOAP notes.

  • PIE model.

  • Focus charting.

  • Charting by exception (CBE).

Focus Charting

• Centers on specific healthcare problems and changes.

• Documentation Items (DAR):

  • Data: What is observed.

  • Action: The actions taken.

  • Response: The client's response.

Charting by Exception (CBE)

• Only document unexpected or unusual findings.

• A shorthand way of documenting normal/ routine findings.

Electronic Documentation Guidelines

• Best Practices:

  • Never use someone else’s login.

  • Strong, unique passwords; change frequently.

  • Log off after completing documentation.

  • Protect monitors/screens from unauthorized viewing.

  • Ensure electronic signatures are correct and credentials noted.

  • Familiarize yourself with downtime procedures.

Documentation Principles

• Must be:

  • Clear, accurate, concise, and accessible.

  • Aids interprofessional communication.

FACT Charting

• Principles:

  • Factual: Report only what is observed.

  • Accurate: Ensure precision in reporting.

  • Complete: All relevant details included.

  • Timely: Document immediately after care.

  • Reminder: "Care not documented is care not done!"

Acceptable Abbreviations

• Use standard abbreviations.

• Familiarize yourself with The Joint Commission's (TJC) Do Not Use list from ATI and Blackboard.

Verbal and Telephone Orders

• Situational Use: Generally limited to emergencies.

• Process for Acceptance:

  • Taken by an RN who repeats the order verbatim.

  • Document the order clearly including date, time, physician’s name, and RN signature.

  • Required cosign by physician within a defined timeframe by most facilities.

Nursing Documentation Components

• Includes:

  • Admission database.

  • Care plans.

  • Progress notes.

  • Medication Administration Record (MAR).

  • Flowsheets (common in acute care).

  • Discharge and transfer summaries.

Legal Considerations in Documentation

• Confidentiality: Ethical obligation to protect patient information (HIPAA regulations).

  • What is confidential:

  • Patient details, treatment received, health conditions, etc.

• Breaches:

  • Risks include displaying information publicly or mishandling electronic communications.

Legal Issues of Documentation

• Nurses' notes are legal documents.

• Each entry should have:

  • Date.

  • Time.

  • Signature.

• Notes should not be altered; follow correction protocols.

• Complete documentation as soon as possible after care.

Patient Rights Regarding Health Records

• Patients have rights to:

  • Access and update their health records.

  • Know who their information is shared with.

  • Request restrictions on certain disclosures.

  • Choose how to receive information.

Written Medical Records

• Challenges of paper records:

  • Difficult to locate information.

  • Fragile, single-user access issues, illegibility of handwriting.

  • Issues with storage.

• Guidelines:

  • Use black ink, include date/time, signature, avoid blank spaces.

Incident Reports

• Definition: Document unusual events involving patients/staff.

  • Examples: Falls, medication errors, equipment-related incidents.

  • Must be factual, objective, and non-judgmental.

• Purpose:

  • To ensure accuracy and not become part of the medical record.

Nursing Informatics

• Definition: Integration of technology and nursing knowledge for managing information and supporting decisions.

• Technology in Healthcare:

  • Bedside computer access and mobile workstations for efficiency.

Benefits of Informatics in Healthcare

• Technology uses data to inform treatment decisions.

• Facilitates better organization and communication, reduces paperwork, and improves safety in medication administration.

Patient Safety Enhancements

• Bar-code medication administration (BCMA) systems reduce errors.

• Computerized decision support systems (DSSs) offer alerts for safe practices.

• Computerized provider order entry (CPOE) integrates with clinical decision support systems.

Record Management

• Implementation: Electronic medical records (EMRs) enhance accessibility for providers.

  • EMRs document single episodes of care, while EHRs maintain longitudinal records of health care.