Documentation
Defined as Anything written or printed within a patient rocord, which may be paper, electronic, or a combinations of both formats.
-Nurses need to follow the basic principles to maintainn confidentiality during the transmission of patient information.
Nurses are:
Legally and ethically obligated to keep all patient information confidential.
Responsible for protecting records from all unauthorized readers
HIPPA
Health Insurance Portability and Accountability Act
HIPPA
Requires that disclosure or requests regarding health information are limited to minimum necessary.
Information regarding a Patients health status may not be released to non-health care team members because:
Legal and ethical obligations require health care providers to keep information strictly confidential.
Current documentation standards require that each patient have an assessment of:
Physical, psychosocial, environmental, self-care, Patient education, knowledge level, and discharge planning needs
Nursing documentation standards are set by:
Federal and state regulations, state statutes, standards of care, and accreditation agencies.
interdisciplinary communication is:
Essential within the health care team.
Records or charts are:
Confidential permanent legal document
Reports are:
Oral Written, or audiotape exchange of information.
Each patient record includes the following:
Patient identification
Informed Consent
Admission data
Nursing diagnoses and care plan
Record of nursing care treatment and evaluation
Medical History and physical examination
Medical diagnoses
Therapeutic orders
Progress notes
Test results
Patient educat
Purpose of Records
Communication, legal documentation, financial billing, education, research, auditing-monitoring
Legal guidelines for Recording
Correct all errors promptly, using correct method.
Record all facts; Do not enter persona; opinions.
Do not leave blank spaces in nurses' notes.
Write legibly in permanent black ink.
If an order was questioned, record that clarification was sought.
Chart
Guidelines for quality documentation and reporting
it needs to be factual, accurate, complete, current and organized
Methods of Documentation
Paper record
Electronic Health Record (EHR)
Problem-Oriented medical record (POMR)
Paper Record
Episode oriented
Key Information may be lost from one episode of care to the next.
EHR
A digital version of a Patients medical record
Integrates all of a Patients information in one record
Improves continuity of care.
POMR
Database
Problem list
Care plan
Progress notes
progress notes
Narrative, SOAP, SOAPIE, PIE, Focus Charting (DAR)
Narrative
Traditional method
SOAP
subjective, objective, assessment, plan
SOAPIE
subjective, objective, assessment, plan, intervention, evaluation
PIE
problem, intervention, evaluation
Focus charting (DAR)
Data, action, response
Charting by exemption (CBE)
Focuses on Documenting Deviations
Case management plan and critical pathways
Incorporate a multidisciplinary approach to care
Variances
Common Record Keeping Forms
Admission nursing history form,
Flow sheets and graphic records, Patient care-summary or Kardex, standardized care plans, discharge summary forms, acuity records
Admission nursing history forms
Guides that nurse through a complete assessment to identify relevant nursing diagnoses or problems.
Flow sheet - Graphic Record
Helps team members quickly see patient trends over time and decreases time spent on writing narrative notes
Patient Care-summary
Computerized systems provide certain basic information in the form of a patient care summary.
Kardex
A portable "flip-over" file or notebook with patient information.
Standardized care plans
Preprinted, established guidelines used to care for patients who have similar health problems
Discharge summary forms
Includes medications, diet, community resources, and follow-up care.
Acuity records
determine the hours of care and staff required for a given group of clients
Home care documentation
Home health care services are reimbursed by Medicare, Medicaid, commercial insurers, as well as other managed care plans.
Each payer has specific guidelines fro establishing eligibility fro home care reimbursement.
Nurses need to document all their servic
Long-term Care Documentation
Assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set.
Quality Documentation describes the services rendered and the patient's response to treatments
hand-off report
Occurs with transfer of patient care
Provides continuity and individualized care.
Reports are quick and efficient.
examples include change of shift reports and transfer reports.
Telephone reports and orders
Situation-background-assessment-recommendation (SBAR)
Document every call
Read back
Incident or occurrence reports
Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient
Follow agency policy.
Health Informatics
Application of computer and information science for managing health-related data
Focus on the patient and the process of care
Goal is to enhance the quality and efficiency of care provided.
Informatics
Study of the retrieval, storage, presentation, and shearing of data, information, and knowledge to provide high-quality, safe patient care.
Health Information System (HIS)
A group of systems used in a health care organization to support and enhance health care.
Clinical Information Systems (CIS)
Monitoring systems, order entry, and laboratory, radiology, and pharmacy systems
Computerized provider order entry (CPOE)
Improves accuracy
Speeds implementation
Improves productivity
Saves money
Nursing information system (NIS)
An NIS is a subspecialty of CIS
clinical decision support system (CDSS)
Computerized prgrams
NIS
Privacy, Confidentiality, and security mechanisms.
Handling and disposal of information:
Destroy anything that is printed with the information is no longer needed.
Know the disposal policies for records in the institution where you work.
Documentation
Defined as Anything written or printed within a patient rocord, which may be paper, electronic, or a combinations of both formats.
-Nurses need to follow the basic principles to maintainn confidentiality during the transmission of patient information.
Nurses are:
Legally and ethically obligated to keep all patient information confidential.
Responsible for protecting records from all unauthorized readers
HIPPA
Health Insurance Portability and Accountability Act
HIPPA
Requires that disclosure or requests regarding health information are limited to minimum necessary.
Information regarding a Patients health status may not be released to non-health care team members because:
Legal and ethical obligations require health care providers to keep information strictly confidential.
Current documentation standards require that each patient have an assessment of:
Physical, psychosocial, environmental, self-care, Patient education, knowledge level, and discharge planning needs
Nursing documentation standards are set by:
Federal and state regulations, state statutes, standards of care, and accreditation agencies.
interdisciplinary communication is:
Essential within the health care team.
Records or charts are:
Confidential permanent legal document
Reports are:
Oral Written, or audiotape exchange of information.
Each patient record includes the following:
Patient identification
Informed Consent
Admission data
Nursing diagnoses and care plan
Record of nursing care treatment and evaluation
Medical History and physical examination
Medical diagnoses
Therapeutic orders
Progress notes
Test results
Patient educat
Purpose of Records
Communication, legal documentation, financial billing, education, research, auditing-monitoring
Legal guidelines for Recording
Correct all errors promptly, using correct method.
Record all facts; Do not enter persona; opinions.
Do not leave blank spaces in nurses' notes.
Write legibly in permanent black ink.
If an order was questioned, record that clarification was sought.
Chart
Guidelines for quality documentation and reporting
it needs to be factual, accurate, complete, current and organized
Methods of Documentation
Paper record
Electronic Health Record (EHR)
Problem-Oriented medical record (POMR)
Paper Record
Episode oriented
Key Information may be lost from one episode of care to the next.
EHR
A digital version of a Patients medical record
Integrates all of a Patients information in one record
Improves continuity of care.
POMR
Database
Problem list
Care plan
Progress notes
progress notes
Narrative, SOAP, SOAPIE, PIE, Focus Charting (DAR)
Narrative
Traditional method
SOAP
subjective, objective, assessment, plan
SOAPIE
subjective, objective, assessment, plan, intervention, evaluation
PIE
problem, intervention, evaluation
Focus charting (DAR)
Data, action, response
Charting by exemption (CBE)
Focuses on Documenting Deviations
Case management plan and critical pathways
Incorporate a multidisciplinary approach to care
Variances
Common Record Keeping Forms
Admission nursing history form,
Flow sheets and graphic records, Patient care-summary or Kardex, standardized care plans, discharge summary forms, acuity records
Admission nursing history forms
Guides that nurse through a complete assessment to identify relevant nursing diagnoses or problems.
Flow sheet - Graphic Record
Helps team members quickly see patient trends over time and decreases time spent on writing narrative notes
Patient Care-summary
Computerized systems provide certain basic information in the form of a patient care summary.
Kardex
A portable "flip-over" file or notebook with patient information.
Standardized care plans
Preprinted, established guidelines used to care for patients who have similar health problems
Discharge summary forms
Includes medications, diet, community resources, and follow-up care.
Acuity records
determine the hours of care and staff required for a given group of clients
Home care documentation
Home health care services are reimbursed by Medicare, Medicaid, commercial insurers, as well as other managed care plans.
Each payer has specific guidelines fro establishing eligibility fro home care reimbursement.
Nurses need to document all their servic
Long-term Care Documentation
Assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set.
Quality Documentation describes the services rendered and the patient's response to treatments
hand-off report
Occurs with transfer of patient care
Provides continuity and individualized care.
Reports are quick and efficient.
examples include change of shift reports and transfer reports.
Telephone reports and orders
Situation-background-assessment-recommendation (SBAR)
Document every call
Read back
Incident or occurrence reports
Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient
Follow agency policy.
Health Informatics
Application of computer and information science for managing health-related data
Focus on the patient and the process of care
Goal is to enhance the quality and efficiency of care provided.
Informatics
Study of the retrieval, storage, presentation, and shearing of data, information, and knowledge to provide high-quality, safe patient care.
Health Information System (HIS)
A group of systems used in a health care organization to support and enhance health care.
Clinical Information Systems (CIS)
Monitoring systems, order entry, and laboratory, radiology, and pharmacy systems
Computerized provider order entry (CPOE)
Improves accuracy
Speeds implementation
Improves productivity
Saves money
Nursing information system (NIS)
An NIS is a subspecialty of CIS
clinical decision support system (CDSS)
Computerized prgrams
NIS
Privacy, Confidentiality, and security mechanisms.
Handling and disposal of information:
Destroy anything that is printed with the information is no longer needed.
Know the disposal policies for records in the institution where you work.