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Chapter 26


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  • •A nurse’s signature on an entry in a record designates accountability for the contents of that entry.[Ask the class: What is the correct method for correcting an error in a paper record? Draw a single line through the error, write the word “error” above it, sign your initials, and date it. Then record the note correctly.]•Accurate record keeping requires objective interpretation of data with precise measurements, correct spelling, and proper use of abbreviations.[See Table 26-1 on text p. 351 Legal Guidelines for Recording for further discussion.]
  • [Ask the class: What would be your first step when you hear a patient report pain as 10 out of 10? What would you record in the chart for Mrs. Smith? Discuss.]
  • [What type of data is provided by Mrs. Smith’s statement? How would you record Mrs. Smith’s statement in your report?]•Mrs. Smith’s statement provides subjective data. No matter what format you use (narrative, SOAP, PIE, etc.), you would record her statement word-for-word, in quotation marks.
  • •The key advantages of an electronic health record (HER) for nursing include providing a means to compare ongoing clinical data about a patient with original baseline information and maintaining an ongoing record of a patient’s health education.•Although the electronic medical record (EMR) contains patient data gathered in a health care setting at a specific time and place and is a part of the EHR, the two terms are frequently used interchangeably. •Computerized information systems provide information about patients in an organized and easily accessible fashion.
  • •A nurse completes a nursing history form when a patient is admitted to a nursing unit.•Flow sheets allow you to quickly and easily enter assessment data about a patient. They use a coding system for data entry.•Many hospitals now have computerized systems that provide information in the form of a patient care summary that is often printed for each patient during each shift. The summary automatically updates as nurses make decisions, and data (e.g., orders) are entered into the computer. •In some settings, a Kardex is kept at the nurses’ station. An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day.[Supply students with these forms. As a class, go over how to fill out the forms. Have students practice before they enter into the hospital for the first time.]
  • •After completing a nursing assessment, the nurse identifies the standard care plans that are appropriate for the patient and places the plans in the patient’s medical record.•Discharge documentation includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions. •Acuity records are not part of a patient’s medical record. They are used for determining the hours of care and the staff required for a given group of patients.[Supply students with these forms. As a class, go over how to fill out the forms. Have students practice before they enter into the hospital for the first time.][See Box 26-3 on text p. 356 Discharge Summary Information for further discussion.]
  • •Use clear, concise descriptions using words that Mrs. Smith understands.•Provide step-by-step descriptions of how to perform a procedure (e.g., home medication administration).•Reinforce explanations with printed instructions.•Identify precautions to follow when performing self-care or administering medications.•Review signs and symptoms of complications the patient needs to report to her health care provider.•Obtain feedback from Mrs. Smith regarding discharge instructions.•List names and phone numbers of health care providers and community resources for Mrs. Smith to contact.•Identify any unresolved problems, including plans for follow-up and continuous treatment.•List actual time of discharge, mode of transportation, and who accompanied Mrs. Smith.•Document the patient encounter accordingly.•Example of a sample discharge note: Instructed when to return to the physician for follow-up care, restrictions on how much to lift at home (no more than 10 lbs), and how to best manage her pain at home. Verbalized understanding of the need to be watchful of lifting techniques, as well as the prescribed pain medication action, side effects, and how often she could take the medication. Informed to notify the doctor if the pain does not subside with the prescribed pain medication dosage. Discharged via wheelchair at 1440 accompanied by daughter-in-law.[See Box 26-3 on text p. 356 Discharge Summary Information for further discussion.]
  • •The government offers incentive payments to health care agencies and providers’ offices that adopt EHRs and use data meaningfully from the EHR to promote safe, high-quality patient care resulting in positive patient outcomes.•Penalties will be assessed to health care facilities that do not adopt EHRs or show meaningful use of data generated from EHRs.
  • •In health care settings, it is a challenge to easily access data and information about patients. The health care information system (HIS) has been developed to make this process easier.•An HIS consists of two major types of systems: clinical information systems (CISs) and administrative information systems. Together the two systems operate to make the entry and communication of data and information more efficient.•For example, a small community hospital uses a nursing information system (NIS); an order entry system; and laboratory, radiology, and pharmacy systems to coordinate its core patient care services.
  • •Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision making in all roles and settings.•An expertly designed CIS based on nursing informatics integrates and supports clinical judgments with up-to-date evidence-based practice. •An effective NIS meets two goals. First, it supports the way that nurses function and work by providing them the flexibility to use the system to view data and collect information, provide patient care, and document a patient’s condition and care provided. Second, it supports and enhances nursing practice through improved access to information and clinical decision-making tools.•As a nurse, you need to know how to use clinical databases within your institution and apply the information so you can deliver high-quality, appropriate patient care.
  • •NISs have two designs. •The nursing process design is the most traditional. It organizes documentation within well-established formats such as admission and postoperative assessment problem lists, care plans, discharge planning instructions, and intervention lists or notes.•The second design model for an NIS is the protocol or critical pathway design. This design offers an interdisciplinary format to manage information.•A clinical decision support system (CDSS) is based on “rules” and “if-then” statements, linking information and/or producing alerts, warnings, or other information for the user. For example, an effective CDSS notifies health care providers of patient allergies before ordering a medication. This enhances patient safety during the medication ordering process.[Image is Figure 26-2 on text p. 360 Model of a nursing clinical decision support system (NCDSS). (Courtesy Frank Lyerla.)]
  • •Successful implementation of a NIS requires preparation, involvement, and commitment of the entire nursing staff.•More advanced systems incorporate into the software standardized nursing languages such as the North American Nursing Diagnosis Association (NANDA) International nursing diagnoses, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC).
  • •Computerized documentation has legal risks. It is possible for anyone to access a computer station within a health care agency and gain information about almost any patient. Protection of information and computer systems is a top priority.•Most security mechanisms for information systems use a combination of logical and physical restrictions to protect information and computer systems.•To protect patient privacy, health care agencies track who accesses patient records and when they access them. •Printing and faxing information from a patient’s record is a primary source for the unauthorized release of information. All papers containing patient information must be destroyed when no longer needed. •Nurses may be responsible for erasing computer files from the hard drive that contain calendars, surgery or diagnostic procedure schedules, or other daily records that contain patient information. •Know and follow the disposal policies for records in the institution where you work.
  • •Any clinician uses programs available on a clinical information system (CIS). •A monitoring system includes devices that automatically monitor and record biometric measurements in critical care and specialty areas. These devices electronically send measurements directly to the nursing documentation system.•Order entry systems allow nurses to order supplies and services from another department.•Computerized provider order entry (CPOE) is a process by which a health care provider directly enters orders for patient care into the hospital information system.•The direct entry of orders eliminates issues related to illegible handwriting and transcription errors.•Orders made through CPOE are integrated within the record and are sent to the appropriate departments (e.g., pharmacy, radiology).
  • Transcript

    • 1. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Chapter 26Documentation andInformatics
    • 2. 2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.ConfidentialityNurses are legally and ethically obligated tokeep all patient information confidential.Nurses are responsible for protecting recordsfrom all unauthorized readers.HIPAA requires that disclosure or requestsregarding health information are limited to theminimum necessary.
    • 3. 3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.1. Information regarding a patient’s health status maynot be released to non–health care team membersbecauseA. Legal and ethical obligations require health careproviders to keep information strictly confidential.B. Regulations require health care institutions todocument evidence of physical and emotional well-being.C. Reimbursement issues related to patient care andprocedures may be of concern.D. Fragmentation of nursing and medical careprocedures may be identified.Quick Quiz!
    • 4. 4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Standards Current documentation standards require thateach patient have an assessment: Physical, psychosocial, environmental, self-care,patient education, knowledge level, and dischargeplanning needs Nursing documentation standards are set byfederal and state regulations, state statutes,standards of care, and accreditationagencies.
    • 5. 5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Interdisciplinary CommunicationWithin the Health Care Team Interdisciplinary communication is essentialwithin the health care team. Records or chart Confidential permanent legal document Reports Oral, written, or audiotaped exchange ofinformation Conferences Team members communicating in a group
    • 6. 6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Interdisciplinary CommunicationWithin the Health Care Team (cont’d) Consultations A professional caregiver giving formal advice toanother caregiver Referrals Arrangement for services by another care provider
    • 7. 7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Purposes of RecordsCommunication Legal documentationReimbursement EducationResearch Auditing/monitoringCommunication Legal documentationReimbursement EducationResearch Auditing/monitoring
    • 8. 8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.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 clarificationwas sought.• Chart only for yourself, not for others.• Avoid generalizations.• Begin each entry with the date/time and end withyour signature and title.• Keep your computer password secure.
    • 9. 9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Guidelines for Quality Documentationand Reporting Factual Accurate Complete Current Organized
    • 10. 10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study Mrs. Smith is a 93-year-old patient with fractures inher lower spine resulting from severe osteoarthritisthat can be treated with surgery. She reports herpain as 10 out of 10.
    • 11. 11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) While completing Mrs. Smiths admissionhistory, you find out that she had a totalknee replacement 3 years ago and pain wasnot well controlled at that time. Mrs. Smith tells you, “Im dreading surgery.Last time, I had such pain when I got out ofbed.”
    • 12. 12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.2. A nurse has just admitted a patient with amedical diagnosis of congestive heart failure.When completing the admission paper work,the nurse needs to recordA. An interpretation of patient behavior.B. Objective data that are observed.C. Lengthy entry using lay terminology.D. Abbreviations familiar to the nurse.Quick Quiz!
    • 13. 13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Methods of Recording Paper record Episode-oriented Key information may be lost from one episode ofcare to the next. Electronic health record (EHR) A digital version of a patient’s medical record Integrates all of a patient’s information in onerecord Improves continuity of care
    • 14. 14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Methods of Recording (cont’d) Narrative The traditional method Problem-oriented medical record (POMR) Database Problem list Care plan Progress notes
    • 15. 15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Methods of Recording:Progress Notes SOAP Subjective, objective, assessment, plan SOAPIE Subjective, objective, assessment, plan,intervention, evaluation PIE Problem, intervention, evaluation Focus charting (DAR) Data, action, response
    • 16. 16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Methods of Reporting Source records A separate section for each discipline Charting by exception (CBE) Focuses on documenting deviations Case management plan and critical pathways Incorporate a multidisciplinary approach to care Variances
    • 17. 17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.3. A nurse records that the patient stated hisabdominal pain is worse now than last night.This is an example ofA. PIE documentation.B. SOAP documentation.C. Narrative charting.D. Charting by exception.Quick Quiz!
    • 18. 18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Common Record-Keeping Forms Admission nursing history form Guides the nurse through a complete assessmentto identify relevant nursing diagnoses or problems Flow sheets and graphic records Help team members quickly see patient trendsover time and decrease time spent on writingnarrative notes Patient care summary or Kardex A portable “flip-over” file or notebook with patientinformation
    • 19. 19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Common Record-Keeping Forms(cont’d) Standardized care plans Preprinted, established guidelines used to care forpatients who have similar health problems Discharge summary forms Acuity records
    • 20. 20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Mrs. Smith’s surgery is successful, and shehas been discharged by her physician. What are some key points to consider inproviding discharge information?
    • 21. 21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Home Care Documentation Medicare has specific guidelines for establishingeligibility for home care. Medicare guidelines for establishing a patient’s homecare cost reimbursement serve as the basis fordocumentation by home care nurses. Documentation is the quality control and justificationfor reimbursement from Medicare, Medicaid, orprivate insurance. Nurses need to document all their services forpayment.
    • 22. 22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Long-Term Health CareDocumentation Governmental agencies are instrumental indetermining standards and policies fordocumentation. The Omnibus Budget Reconciliation Act of1987 includes Medicare and Medicaidlegislation for long-term care documentation. The department of health in states governsthe frequency of written nursing records.
    • 23. 23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Reporting Hand-off report Occurs with transfer of patient care Provides continuity and individualized care Reports are quick and efficient.
    • 24. 24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Reporting (cont’d) 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 consistentwith the routine operation of a health care unit orthe routine care of a patient Follow agency policy
    • 25. 25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.4. A patient you are assisting has fallen in theshower. You must complete an incident report.The purpose of an incident report is toA. Exchange information among health caremembers.B. Provide information about patients from oneunit to another unit.C. Ensure proper care for the patient.D. Aid in the hospital’s quality improvementprogram.Quick Quiz!
    • 26. 26Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Health Informatics Application of computer and informationscience for managing health-related data Focus on the patient and the process of care Goal is to enhance the quality and efficiencyof care provided. Driven by the Health Information Technologyfor Economic and Clinical Health Act(HITECH)
    • 27. 27Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Nursing Informatics A specialty that integrates nursing science,computer science, and information science tomanage and communicate data, information,and knowledge in nursing practice Health care information system (HIS): a groupof systems used in a health care organizationto support and enhance health care Consists of one or more Computerized clinical information systems (CISs) Administrative information systems
    • 28. 28Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Nursing Informatics (cont’d)A specialty that integrates nursingscience, computer science, andinformation science to manage andcommunicate data, information, andknowledge in nursing practiceSupports the way thatnurses function and workSupports and enhances nursing practicethrough improved access to information andclinical decision-making tools
    • 29. 29Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Nursing Information Systems Two designs ofNISs Nursing processdesign Protocol or criticalpathway design Clinical decisionsupport systems(CDSSs) Used to supportdecision making
    • 30. 30Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Advantages of NISsIncreased time to spend with patientsBetter access to informationEnhanced quality of documentationReduced errors of omissionReduced hospital costsIncreased nurse job satisfactionCompliance with accrediting agenciesCommon clinical database development
    • 31. 31Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Nursing Information Systems (cont’d) Privacy, confidentiality, and security mechanisms Legal risks Handling and disposal of information Protection of the confidentiality of patients’ healthinformation and the security of computer systems aretop priorities that include log-in processes, audittrails, firewalls, data recovery processes, and policiesabout handling and disposing of data to protectpatient information.
    • 32. 32Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Clinical Information Systems A hospital information system consists of two majortypes of information systems: CISs andadministrative information systems. CIS = Monitoring systems, order entry, andlaboratory, radiology, and pharmacy systems Computerized provider order entry (CPOE) Improves accuracy Speeds implementation Improves productivity Saves money