Chapter 26 Documentation and Informatics Copyright 2013 2009

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Chapter 26 Documentation and Informatics Copyright © 2013, 2009, 2005 by Mosby, an imprint

Chapter 26 Documentation and Informatics Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.

Confidentiality Nurses are legally and ethically obligated to keep all patient information confidential. Nurses

Confidentiality Nurses are legally and ethically obligated to keep all patient information confidential. Nurses are responsible for protecting records from all unauthorized readers. HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 2

Quick Quiz! 1. Information regarding a patient’s health status may not be released to

Quick Quiz! 1. Information regarding a patient’s health status may not be released to non–health care team members because A. Legal and ethical obligations require health care providers to keep information strictly confidential. B. Regulations require health care institutions to document evidence of physical and emotional wellbeing. C. Reimbursement issues related to patient care and procedures may be of concern. D. Fragmentation of nursing and medical care procedures may be identified. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 3

Standards Current documentation standards require that each patient have an assessment: Ø Physical, psychosocial,

Standards Current documentation standards require that each patient have an assessment: Ø 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. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 4

Interdisciplinary Communication Within the Health Care Team Interdisciplinary communication is essential within the health

Interdisciplinary Communication Within the Health Care Team Interdisciplinary communication is essential within the health care team. Records or chart Ø Reports Ø Confidential permanent legal document Oral, written, or audiotaped exchange of information Conferences Ø Team members communicating in a group Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 5

Interdisciplinary Communication Within the Health Care Team (cont’d) Consultations Ø A professional caregiver giving

Interdisciplinary Communication Within the Health Care Team (cont’d) Consultations Ø A professional caregiver giving formal advice to another caregiver Referrals Ø Arrangement for services by another care provider Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 6

Purposes of Records Communication Legal documentation Reimbursement Education Research Auditing/monitoring Copyright © 2013, 2009,

Purposes of Records Communication Legal documentation Reimbursement Education Research Auditing/monitoring Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 7

Legal Guidelines for Recording • • • Correct all errors promptly, using the correct

Legal Guidelines for Recording • • • Correct all errors promptly, using the correct method. Record all facts; do not enter personal opinions. Do not leave blank spaces in nurses’ notes. Write legibly in permanent blank ink. If an order was questioned, record that clarification was sought. Chart only for yourself, not for others. Avoid generalizations. Begin each entry with the date/time and end with your signature and title. Keep your computer password secure. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 8

Guidelines for Quality Documentation and Reporting Factual Accurate Complete Current Organized Copyright © 2013,

Guidelines for Quality Documentation and Reporting Factual Accurate Complete Current Organized Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 9

Case Study Mrs. Smith is a 93 -year-old patient with fractures in her lower

Case Study Mrs. Smith is a 93 -year-old patient with fractures in her lower spine resulting from severe osteoarthritis that can be treated with surgery. She reports her pain as 10 out of 10. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 10

Case Study (cont’d) While completing Mrs. Smith's admission history, you find out that she

Case Study (cont’d) While completing Mrs. Smith's admission history, you find out that she had a total knee replacement 3 years ago and pain was not well controlled at that time. Mrs. Smith tells you, “I'm dreading surgery. Last time, I had such pain when I got out of bed. ” Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 11

Quick Quiz! 2. A nurse has just admitted a patient with a medical diagnosis

Quick Quiz! 2. A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record A. An interpretation of patient behavior. B. Objective data that are observed. C. Lengthy entry using lay terminology. D. Abbreviations familiar to the nurse. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 12

Methods of Recording Paper record Ø Ø Episode-oriented Key information may be lost from

Methods of Recording Paper record Ø Ø Episode-oriented Key information may be lost from one episode of care to the next. Electronic health record (EHR) A digital version of a patient’s medical record Integrates all of a patient’s information in one record Ø Improves continuity of care Ø Ø Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 13

Methods of Recording (cont’d) Narrative Ø The traditional method Problem-oriented medical record (POMR) Ø

Methods of Recording (cont’d) Narrative Ø The traditional method Problem-oriented medical record (POMR) Ø Ø Database Problem list Care plan Progress notes Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 14

Methods of Recording: Progress Notes SOAP Ø SOAPIE Ø Subjective, objective, assessment, plan, intervention,

Methods of Recording: Progress Notes SOAP Ø SOAPIE Ø Subjective, objective, assessment, plan, intervention, evaluation PIE Ø Subjective, objective, assessment, plan Problem, intervention, evaluation Focus charting (DAR) Ø Data, action, response Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 15

Methods of Reporting Source records Ø A separate section for each discipline Ø Focuses

Methods of Reporting Source records Ø A separate section for each discipline Ø Focuses on documenting deviations Ø Ø Incorporate a multidisciplinary approach to care Variances Charting by exception (CBE) Case management plan and critical pathways Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 16

Quick Quiz! 3. A nurse records that the patient stated his abdominal pain is

Quick Quiz! 3. A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of A. PIE documentation. B. SOAP documentation. C. Narrative charting. D. Charting by exception. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 17

Common Record-Keeping Forms Admission nursing history form Ø Flow sheets and graphic records Ø

Common Record-Keeping Forms Admission nursing history form Ø Flow sheets and graphic records Ø Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems Help team members quickly see patient trends over time and decrease time spent on writing narrative notes Patient care summary or Kardex Ø A portable “flip-over” file or notebook with patient information Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 18

Common Record-Keeping Forms (cont’d) Standardized care plans Ø Preprinted, established guidelines used to care

Common Record-Keeping Forms (cont’d) Standardized care plans Ø Preprinted, established guidelines used to care for patients who have similar health problems Discharge summary forms Acuity records Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 19

Case Study (cont’d) Mrs. Smith’s surgery is successful, and she has been discharged by

Case Study (cont’d) Mrs. Smith’s surgery is successful, and she has been discharged by her physician. What are some key points to consider in providing discharge information? Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 20

Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. Medicare

Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. Medicare guidelines for establishing a patient’s home care cost reimbursement serve as the basis for documentation by home care nurses. Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. Nurses need to document all their services for payment. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 21

Long-Term Health Care Documentation Governmental agencies are instrumental in determining standards and policies for

Long-Term Health Care Documentation Governmental agencies are instrumental in determining standards and policies for documentation. The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation. The department of health in states governs the frequency of written nursing records. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 22

Reporting Hand-off report Ø Ø Ø Occurs with transfer of patient care Provides continuity

Reporting Hand-off report Ø Ø Ø Occurs with transfer of patient care Provides continuity and individualized care Reports are quick and efficient. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 23

Reporting (cont’d) Telephone reports and orders Situation-background-assessmentrecommendation (SBAR) Ø Document every call Ø Read

Reporting (cont’d) Telephone reports and orders Situation-background-assessmentrecommendation (SBAR) Ø Document every call Ø Read back Ø 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 Ø Follow agency policy Ø Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 24

Quick Quiz! 4. A patient you are assisting has fallen in the shower. You

Quick Quiz! 4. A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to A. Exchange information among health care members. B. Provide information about patients from one unit to another unit. C. Ensure proper care for the patient. D. Aid in the hospital’s quality improvement program. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 25

Health Informatics Application of computer and information science for managing health-related data Focus on

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. Driven by the Health Information Technology for Economic and Clinical Health Act (HITECH) Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 26

Nursing Informatics A specialty that integrates nursing science, computer science, and information science to

Nursing Informatics A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice Health care information system (HIS): a group of systems used in a health care organization to support and enhance health care Consists of one or more Ø Ø Computerized clinical information systems (CISs) Administrative information systems Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 27

Nursing Informatics (cont’d) A specialty that integrates nursing science, computer science, and information science

Nursing Informatics (cont’d) A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice Supports the way that nurses function and work Supports and enhances nursing practice through improved access to information and clinical decision-making tools Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 28

Nursing Information Systems Two designs of NISs Nursing process design Ø Protocol or critical

Nursing Information Systems Two designs of NISs Nursing process design Ø Protocol or critical pathway design Ø Clinical decision support systems (CDSSs) Ø Used to support decision making Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 29

Advantages of NISs Increased time to spend with patients Better access to information Enhanced

Advantages of NISs Increased time to spend with patients Better access to information Enhanced quality of documentation Reduced errors of omission Reduced hospital costs Increased nurse job satisfaction Compliance with accrediting agencies Common clinical database development Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 30

Nursing Information Systems (cont’d) Privacy, confidentiality, and security mechanisms Ø Legal risks Handling and

Nursing Information Systems (cont’d) Privacy, confidentiality, and security mechanisms Ø Legal risks Handling and disposal of information Protection of the confidentiality of patients’ health information and the security of computer systems are top priorities that include log-in processes, audit trails, firewalls, data recovery processes, and policies about handling and disposing of data to protect patient information. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 31

Clinical Information Systems A hospital information system consists of two major types of information

Clinical Information Systems A hospital information system consists of two major types of information systems: CISs and administrative information systems. CIS = Monitoring systems, order entry, and laboratory, radiology, and pharmacy systems Computerized provider order entry (CPOE) Ø Ø Improves accuracy Speeds implementation Improves productivity Saves money Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 32

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