Chapter 26 - Documentation and Informatics

Documentation:

Documentation is anything written or printed that the nurse relies on as record or proof of patient actions and activities.

According to HIPPA (Health Insurance Portability and Accountability Act), to eliminate barriers that could delay care, providers are: (2)

a. Providers are required to notify patients of their privacy policy and make a reasonable effort to get written acknowledgment of this notification
b. HIPAA requires that disclosure or requests regarding health information are limited to the minimum nece

The standards of documentation by The Joint Commission require:

The standards of documentation by The Joint Commission require documentation within the context of the nursing process, as well as evidence of patient and family teaching and discharge planning

Communication

c. Means by which patient needs and progress, individual therapies, patient education, and discharge planning are conveyed to others in the health care team

Legal documentation

e. Describes exactly what happens to the patient and must follow agency standards

Diagnostic-related groups (DRGs)

f. Classification system based on patients' medical diagnoses that supports reimbursement

Education

b. Learning the nature of an illness and the individual patient's responses

Research

d. Gathering of statistical data of clinical disorders, complications, therapies, recover, and deaths

Auditing

a. Objective, ongoing reviews to determine the degree to which quality improvement standards are met

Five important guidelines must be followed to ensure quality documentation and reporting. Explain each one.
Factual

A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells.

Five important guidelines must be followed to ensure quality documentation and reporting. Explain each one.
Accurate

An accurate record uses exact measurements, contains concise data, contains only approved abbreviations, uses correct spelling, and identifies the date and caregiver.

Five important guidelines must be followed to ensure quality documentation and reporting. Explain each one.
Complete

A complete record contains all appropriate and essential information.

Five important guidelines must be followed to ensure quality documentation and reporting. Explain each one.
Current

Current records contain timely entries with immediate documentation of information as it is collected from the patient.

Five important guidelines must be followed to ensure quality documentation and reporting. Explain each one.
Organized

Organized records communicate information in a logical order.

Narrative

j. Story-like format that has the tendency to have repetitious information and be time consuming

Problem-oriented medical record (POMR)

c. Database, problem list, care plan, and progress notes

SOAP

i. Subjective, objective, assessment, and plan

SOAPIE

f. SOAP with intervention and evaluation added

PIE

h. Problem, intervention, and evaluation with a nursing origin

Electronic health record (EHR)

g. Electronic record of patient information generated whenever a patient accesses medical care in any health care setting

Source record

e. Separate section for each discipline

Charting by exception

b. Focuses on deviations from the established norm or abnormal findings; highlights trends and changes

Case management

a. Incorporates a multidisciplinary approach to documenting patient care

Critical pathways

d. Multidisciplinary care plans that include patient problems, key interventions, and expected outcomes

Admission nursing history forms

c. Provides current information that is accessible to all members of the health care team

Flow sheets

e. Has activity, treatment, and nursing care plan sections that organize information for quick reference

Kardex

b. Level is based on the type and number of nursing interventions required over a 24-hour period

Acuity records

f. Preprinted, established guidelines used to car for the patient

Standardized care plans

a. Includes medications, diet, community resources, and follow-up care

Discharge summary forms

d. Provides baseline data to compare with changes in the patient's condition

Identify the nine major areas to include in a hand-off report. (9)

a. Provide only essential background information.
b. Identify the patient's nursing diagnosis or health care problems and their related causes
c. Describe objective measurements or observations about condition and responses to the health problem.
d. Share

List the information that needs to be documented with telephone reports.

With telephone reports, the nurse includes when the call was made, who made it, who was called, to whom information was given, what information was given, and what information was received.

List the guidelines the nurse should follow when receiving telephone orders from health care providers. (6)

a. Clearly determine the patient's name, room number, and diagnosis
b. Repeat all prescribed orders back to the physician.
c. Use clarification questions.
d. Write TO or VO, including the date and time, name of the patient, and the complete order, and sig

An incident or occurrence is ________. Give some examples of incidents. __________

An incident or occurrence is any event that is not consistent with the routine operation of a health care unit or routine care of a patient. Examples include patient falls, needle-stick injuries, a visitor with an illness, medication errors, accidental om

Define health informatics

Health Informatics is the application of computer and information science in all biomedical sciences to facilitate acquisition, processing, interpretation, optimal use, and communication.

Nursing informatics integrates:

Nursing informatics integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

Identify the two nursing information systems that are available. (2)

a. Nursing process, NANDA, NIC, and NOC
b. Protocol or critical pathway

Identify the advantages of a nursing information system. (8)

a. Increased time to spend with patients
b. Better access to information
c. Enhanced quality of documentation
d. Reduced errors of omission
e. Reduced hospital costs
f. Increased nurse job satisfaction
g. Compliance with requirements of accrediting agenci

The primary purpose of a patient's medical record is to:
1. Provide validation for hospital charges.
2. Satisfy requirements of accreditation agencies.
3. Provide the nurse with a defense against malpractice.
4. Communicate accurate, timely information ab

4. The patient's medical record should be the most current and accurate continuous source of information about the patient's health care status.

Which of the following is correctly charted according to the size guidelines for quality recording?
1. "Was depressed today."
2. "Respirations rapid; lung sounds clear."
3. "Had a good day. Up and about in room."
4. "Crying. States she doesn't want visito

4. When recording subjective data, document the patient's exact words within quotation marks whenever possible.

During change-of-shift report:
1. Two or more nurses always visit all patients to review their plan of care.
2. The nurse should identify nursing diagnoses and clarify patient priorities.
3. Nurses should exchange judgments they have made about patient at

2. An effective change-of-shift report describes each patient's health status and lets staff on the next shift know what care the patients will require.

An incident report is:
1. A legal claim against a nurse for negligent nursing care
2. A summary report of all falls occurring on a nursing unit
3. A report of an event inconsistent with the routine care of a patient
4. A report of a nurse's behavior submi

3. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a patient.

If an error is made while recording, the nurse should:
1. Erase it or scratch it out.
2. Leave a blank space in the note.
3. Draw a single line through the error and initial it.
4. Obtain a new nurse's note and rewrite the entries.

3. Do not erase, apply correction fluid, or scratch out errors made while recording; it may appear as if you were attempting to hide information or deface the record.