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chapter 19

Terms in this set (56)

Purposes of Patient Records
vCommunication
vDiagnostic and therapeutic orders
vCare planning
vQuality process and performance improvement
vResearch; decision analysis
vEducation
vCredentialing, regulation, and legislation
vReimbursement
vLegal and historical documentation
Characteristics of Effective Documentation
vConsistent with professional and agency standards
vComplete
vAccurate
vConcise
vFactual
vOrganized and timely
vLegally prudent
vConfidential
Elements of Documentation
vContent
vTiming
vFormat
vAccountability
vConfidentiality
What Is Confidential?
vAll information about patients written on paper, spoken aloud, saved on computer
oName, address, phone, fax, social security number
oReason the person is sick
oTreatments patient receives
oInformation about past health conditions
Tell whether the following statement is true or false.
A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality.
A. True
B. False
A
Potential Breaches in Patient Confidentiality
vDisplaying information on a public screen
vSending confidential e-mail messages via public networks
vSharing printers among units with differing functions
vDiscarding copies of patient information in trash cans
vHolding conversations that can be overheard
vFaxing confidential information to unauthorized persons
vSending confidential messages overheard on pagers
Tell whether the following statement is true or false.
A patient has the right to obtain, review, and revise the patient information in his or her health record.
A. True
B. False
B
Patient Rights
Patients have the right to:
vSee and copy their health record
vUpdate their health record
vGet a list of disclosures
vRequest a restriction on certain uses or disclosures
vChoose how to receive health information
Policy for Receiving Verbal Orders in an Emergency
vRecord the orders in patient's medical record.
vRead back the order to verify accuracy.
vDate and note the time orders were issued in emergency.
vRecord verbal order and name of the physician issuing the order, followed by nurse's name and initials.
Policy for Physician or Nurse Practitioner Review of Verbal Orders
vReview orders for accuracy.
vSign orders with name, title, and pager number.
vDate and note time orders signed.
Duties of RN Receiving Telephone Orders
vRecord the orders in patient's medical record.
vRead orders back to practitioner to verify accuracy.
vDate and note the time orders were issued.
vRecord telephone orders, and full name and title of physician or nurse practitioner who issued orders.
vSign the orders with name and title.
Tell whether the following statement is true or false.
One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care.
A. True
B. False
A
Purposes of Recording Data
vFacilitate quality, evidence-based patient care
vServe as a financial and legal record
vHelp in clinical research
vSupport decision analysis
Two Types of Personal Health Records (PHRs)
vStandalone personal health records:
vTethered/connected personal health records:
Standalone personal health records:
Patients fill in information from their own records; the information is stored on patients' computers or the Internet.
Tethered/connected personal health records:
: Linked to a specific health care organization's electronic health record (EHR) system or to a health plan's information system.
Benefits of a Health Information Exchange #1
vProvides a vehicle for improving quality and safety of patient care
vProvides a basic level of interoperability among EHRs maintained by individual physicians and organizations
vStimulates consumer education and patients' involvement in their own health care
vHelps public health officials meet their commitment to the community
Benefits of a Health Information Exchange #2
vCreates a potential loop for feedback between health-related research and actual practice
vFacilitates efficient deployment of emerging technology and health care services
vProvides the backbone of technical infrastructure for leverage by national and state-level initiatives
Methods of Documentation
vSource-oriented records
vProblem-oriented medical records
vPIE charting (problem, intervention, evaluation)
vFocus charting
vCharting by exception
vCase management model
vComputerized documentation/Electronic health records (EHRs)
Which method of documentation is unique in that it does not develop a separate care plan but instead incorporates the care plan into the progress notes?
A. Source-oriented records
B. Problem-oriented records
C. PIE (problem, intervention, evaluation)
D. Focus charting
C
Major Components of Problem-Oriented Medical Record
vDefined database
vProblem list
vCare plans
vProgress notes
vSOAP format
Formats for Nursing Documentation
vInitial nursing assessment
vCare plan; patient care summary
vCritical collaborative pathways
vProgress notes
vFlow sheets and graphic records
vMedication record
vAcuity record
vDischarge and transfer summary
vLong-term care and home health care documentation
Types of Flow Sheets
vGraphic record
v24-hour fluid balance record
vMedication administration record (MAR)
v24-hour patient care record
vAcuity records
Medicare Requirements for Home Health Care
vPatient is homebound and still needs skilled nursing care.
vRehabilitation potential is good (or patient is dying).
vThe patient's status is not stabilized.
vThe patient is making progress in expected outcomes of care.
Four Basic Components of RAI (Resident Assessment Tool)
vMinimum data set
vTriggers
vResident assessment protocols
vUtilization guidelines
Benefits of RAI
vResidents respond to individualized care.
vStaff communication becomes more effective.
vResident and family involvement increases.
vDocumentation becomes clearer.
Hand-off Communication/ISBARR
vIdentity/Introduction
vSituation
vBackground
vAssessment
vRecommendation
vRead back of orders/response
Change of Shift/Hand-off Reports
vBasic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians
vCurrent appraisal of each patient's health status
vCurrent orders (especially any newly changed orders)
vAbnormal occurrences during your shift
vAny unfilled orders that need to be continued onto the next shift
vPatient/family questions, concerns, needs
vReports on transfers/discharges
Telephone/Telemedicine Reports
vIdentify yourself and the patient, and state your relationship to the patient.
vReport concisely and accurately the change in the patient's condition that is of concern and what has already been done in response to this condition.
vReport the patient's current vital signs and clinical manifestations.
vHave the patient's record at hand to make knowledgeable responses to any physician's inquiries.
vConcisely record time and date of the call, what was communicated, and physician's response.
Conferring about Care
vConsultations and referrals
vNursing and interdisciplinary team care conferences
vNursing care rounds
vPurposeful rounding
Eight Behaviors of Purposeful Rounding
vUse Opening Key Words (C-I-CARE) with PRESENCE.
vAccomplish scheduled tasks.
vAddress four Ps.
vAddress additional personal needs, questions.
vConduct environmental assessment.
vAsk "Is there anything else I can do for you? I have time."
vTell the patient when you will be back.
vDocument the round.
Health care smart card:
The health care smart card is similar to a credit card, with a magnetic strip that either contains vital emergency health care information or creates a link to information in another location. Using the cardholder's personal identification number (PIN) and entering the card into a reader enables emergency providers to retrieve designated health-related information about a given patient. People should always carry their PIN with them to permit access in an emergency.
Electronic health record (EHR)
The EHR is the patient care record created when facilities under different ownership share their data. The goal is for this sharing to be nationwide, creating a situation in which a person's health care record is accessible by designated health care providers anywhere in the nation. The patient will decide which portions of a record will be available to whom
Electronic medical record (EMR)
An EMR is an electronic patient care record created by a facility or facilities having common ownership. Although these EMRs today are often called EHRs, they are not true EHRs because the data are not shared between providers in facilities under different ownership
Health information exchange (HIE)
An HIE is an organization that provides services to enable the electronic sharing of health-related information
Electronic database:
An electronic database is a collection of data that allows easy searching and easy retrieval of similar pieces of data from many records.
Additional examples of breaches of confidentiality and security include the following:
-Discussing patient information in any public area where those who have no need to know the information can overhear
-Leaving patient medical information in a public area
-Leaving a computer unattended in an accessible area with medical record information unsecured
-Failing to log off a computer terminal
Sharing or exposing passwords
-Copying or providing data, either on paper or in machine-readable form, for yourself, coworkers, or any other party, except as required to fulfill job responsibilities
-Improperly accessing, reviewing, or releasing birth dates and addresses of friends or relatives, or requesting another person to do so
-Improperly accessing, reviewing, or releasing the record of a patient out of concern or curiosity, or requesting another person to do so
Source-Oriented Records
is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, health care providers, laboratory, x-ray personnel, and so on.
Problem-Oriented Medical Records
is organized around a patient's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of patient problems and contributes collaboratively to the care plan. Progress notes clearly focus on patient problems. The POMR includes the defined database, problem list, care plans, and progress notes
The SOAP format
(Subjective data, Objective data, Assessment [the caregiver's judgment about the situation], Plan) is used to organize entries in the progress notes of the POMR. Variants of the SOAP format include SOAPE, SOAPIE, and SOAPIER (Intervention, Evaluation, and Response). Caregivers select numbered problems from the master list on the front of the patient record and then work up the problem or "SOAP it" on the progress sheet. Some nurses believe that the SOAP method of charting focuses too narrowly on problems, and advocate instead a return to the traditional narrative format.
PIE Charting: Problem, Intervention, Evaluation
is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified).
Focus Charting
is to bring the focus of care back to the patient and the patient's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a patient and patient care. The focus may be a patient strength, problem, or need. Topics that may appear in the focus column include patient concerns and behaviors, therapies and responses, changes of condition, and significant events such as teaching, consultation, monitoring, management of activities of daily living, or assessment of functional health patterns. The narrative portion of focus charting uses the Data-Action-Response (DAR) format
Charting by Exception
is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. Benefits of this approach include less time needed for charting (freeing more time for direct patient care), a greater emphasis on significant data, easy retrieval of significant data, timely bedside charting, standardized assessment, greater interdisciplinary communication, better tracking of important patient responses, and lower costs.
Collaborative pathways
also called critical pathways or care maps—are used in the case management model. The collaborative pathway specifies the care plan linked to expected outcomes along a timeline In some documentation systems, the collaborative pathway is part of a computerized documentation system that integrates the collaborative pathway and documentation flow sheets designed to match each day's expected outcomes.
occurrence charting or variance charting
unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate. The variances most likely to be documented are those that affect quality, cost, or length of stay.
Progress Notes
is to inform caregivers of the progress a patient is making toward achieving expected outcomes. The method used to record the patient's progress depends on the documentation system being used. Common examples include narrative nursing notes, SOAP notes, PIE notes, focus charting, CBE, and the case management model.
Flow Sheets and Graphic Records
are documentation tools used to efficiently record routine aspects of nursing care Well-designed flow sheets enable nurses to quickly document the routine aspects of care that promote patient goal achievement, safety, and well-being. The graphic record is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.
Medication Administration Records (MARs)
must include documentation of all the medications administered to the patient (drug, dose, route, time), the nurse administering the drug, and, for some medications (e.g., analgesics), the reason the drug was administered and its effectiveness. Some electronic medication administration records (eMARs) allow providers to look up detailed information about a medication's indications, contraindications, expected and adverse effects, and safe dosage ranges.
Acuity Records
Twenty-four-hour reports are increasingly used in conjunction with acuity reports, with which nurses rank patients as high-to-low acuity in relation to both the patient's condition and need for nursing assistance or intervention. A trauma patient whose condition is changing rapidly and who requires intensive nurse monitoring and intervention merits a higher acuity rank than a patient whose condition is stable.
Home Health Care Documentation
Documentation of home health care visits that reports the patient's progress serves multiple purposes. Sent to the attending health care provider with a request for signed medical orders to continue treatment, these records ensure continuity of care. Sent to third-party payers, they establish the need for continuing home care with continued reimbursement for necessary services. Medicare, for example, reviews progress summaries to determine whether a patient meets one of these Medicare requirements:
The Outcome and Assessment Information Set (OASIS) is a group of data elements that:
represent core items of a comprehensive assessment for an adult home care patient.
form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI).
Minimum data set
A core set of screening, clinical, and functional status elements that form the foundation of the comprehensive assessment of all residents in long-term care facilities certified to participate in Medicare or Medicaid. The items in the minimum data set standardize communication about resident problems and condition
Triggers
Specific resident responses for one or a combination of minimum data set elements that identify residents who either have or are at risk for developing specific functional problems and who require further evaluation using resident assessment protocols
Resident assessment protocols
Structured, problem-oriented frameworks for organizing minimum data set information and examining additional clinically relevant information about a resident. Resident assessment protocols help identify social, medical, nursing, and psychological problems and form the basis for individualized care planning.
Utilization guidelines
Specified in state operation manuals that direct when and how to use the RAI.
ISBAR
-Identity/Introduction: Communicate who you are, where you are, and why you are communicating.
-Situation: Communicate what is occurring and why the patient is being handed off to another department or unit.
-Background: Explain what led up to the current situation and put in context if necessary.
-Assessment: Give your impression of the problem.
-Recommendation: Explain what you would do to correct the problem.
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