RECORDS A record is a permanent written communication that documents information relevant to a client’s health care management, e.g. a client chart is a continuing account of client’s health care status and need. -Potter and Perry R S MEHTA, MSND 2
PURPOSES OF RECORDS1.Supply data that are essential for programme planning and evaluation.2. To provide the practitioner with data required for the application of professional services for the improvement of family’s health. R S MEHTA, MSND 3
3. Records are tools of communication between health workers, the family, and other development personnel.4. Effective health records shows the health problem in the family and other factors that affect health.5. A record indicates plans for future.6. It provides baseline data to estimate the long-term changes related to services. R S MEHTA, MSND 4
Administrative purpose of clinical records• Legal documents: poisoning, assault, rape, LAMA, burn etc.• Research or statistics: rates• Audit and nursing audit• Quality of care• Continuity of care• Informative purposes: M E N census• Teaching purpose of students• Diagnostic purposes: test reports
Importance of Records in Hospital1. For the individual and family:- Serve the history of the client- Assist in continuity of care- Evidence to support if legal issues arise- Assess health needs, research and teaching. R S MEHTA, MSND 6
2. For the Doctor:- Serve the guide for diagnosis, treatment, follow-up and evaluation.- Indicate progress and continuity of care.- Self-evaluation of medical practice- Protect doctor in legal issues- Used for teaching and research R S MEHTA, MSND 7
3. For the nurses:- Document nursing service rendered- Shows progress- Planning and evaluation of service for future improvement- Guide for professional growth- Judge the quality and quantity of work done- Communication tool between nurse and other staff involved in the care.- Indicate plan for future R S MEHTA, MSND 8
4. For authorities:- Statistical information- Administrative control- Future reference- Evaluation of care in terms of quality, quantity and adequacy.- Help supervisor to evaluate service- Guide staff and students- Legal evidence of service render by each employee- Provide justification of expenditure of funds. R S MEHTA, MSND 9
Purposes of records: summary1.COMMUNICATION2.FINANCIAL BILLING3.EDUCATION4.ASSESSMENT5.RESEARCH6.AUDITING AND MONITORING7.LEGAL ASPECT R S MEHTA, MSND 10
Records in the nursing office & Unit- Administrative records: Organogram, job description, procedure manual- Personnel records: personal files, records- Patient related records: patients records send to Medical director- Leave record, duty roster, meeting minutes, budget etc- Miscellaneous: circular, round book, formats etc R S MEHTA, MSND 11
PRINCIPLES OF RECORD WRITING1. Nurses should develop their own method of expression and form in record writing.2.Records should be written clearly & appropriately.3.Records should contain facts based on observation, conversation and action. R S MEHTA, MSND 12
4. Select relevant facts and the recording should be neat, complete and uniform5.Records should be written immediately after an interview.6. Records are confidential documents. R S MEHTA, MSND 13
FILLING OF RECORDSDifferent systems may be adopteddepending on the purposes of the recordsand on the merits of a system.The records could be arranged:– Alphabetically– Numerically– Geographically and– With index cards R S MEHTA, MSND 14
REGISTERS• It provides indication of the total volume of service and type of cases seen. Clerical assistance may be needed for this. Registers can be of varied types such as:• immunization register,• clinic attendance register,• family planning register,• birth register and• death register. R S MEHTA, MSND 15
GUIDELINES FOR QUALITY DOCUMENTATION AND REPORTING….a) Factual basisb) accuracyc) completenessd) accuracye) organizationf) confidentiality R S MEHTA, MSND 16
NURSES RESPONSIBILITY FORRECORD KEEPING AND REPORTING• Keep under safe custody of nurses.• No individual sheet should be separated.• Not accessible to patients and visitors.• Strangers is not permitted to read records.• Records are not handed over to the legal advisors without written permission of the administration.• Handed carefully, not destroyed. R S MEHTA, MSND 17
cont..• Identified with bio-data of the patients such as name , age, admission number, diagnosis, etc. (Legal Issues?)• Never sent outside of the hospital without the written administrative permission. R S MEHTA, MSND 18
Patient Verification• Two identifiers: patient name and date of birth• Compare to ID band, consents, diagnostic images, and all other patient documentation related to the procedure
SYSTEM OF MEDICAL RECORD• In the modern age, Medical Record has its utility and usefulness and is a very broad based indicator of patients care.• The policy is to keep indoor patient Records for 10 years• The OPD registers for 5 years• The record which is register for legal purposes in Maintained for 10 years or till final decision at the court of Law. R S MEHTA, MSND 20
FUNCTIONS OF MEDICAL RECORD DEPARTMENT1. Daily receipt of case sheets pertaining to discharge and expired patients from various wards, there checking and assembly.2. Daily compilation of Hospital census report.3. Maintains & retrieval of records for patient care and research study.4. Completion and Procession of Hospital statistics and preparation on different periodical reports on morbidity and mortality.
5. Online registration of vital events of Birth & Death.6. Issuing Birth & Death certificated up to one year.7. Dealing with Medico Legal records and attending the courts on summary.8. Arrangement & Supervision of enquiry and admission office. R S MEHTA, MSND 22
• Reports can be compiled daily, weekly, monthly, quarterly and annually.• Report summarizes the services of the nurse and/ or the agency.• Reports may be in the form of an analysis of some aspect of a service.• These are based on records and registers and so it is relevant for the nurses to maintain the records regarding their daily case load, service load and activities.• Thus the data can be obtained continuously and for a long period. R S MEHTA, MSND 24
NURSING REPORTSo Reports are information about a patient either written or oral. -sr. Nancyo A report is a summary of activities or observations seen, performed or heard. -Potter and Perry R S MEHTA, MSND 25
PURPOSES OF WRITING REPORTS• To show the kind and quantity of service rendered over to a specific period.• To show the progress in reaching goals.• As an aid in studying health conditions.• As an aid in planning.• To interpret the services to the public and to other interested agencies. R S MEHTA, MSND 26
TYPE OF REPORTS1)Change of shift report2) telephone reports3)Telephone orders4)Transfer reports5)Incident reports6)Legal reports R S MEHTA, MSND 27
CRITERIA OF GOOD REPORTCan be made promptlyClear, concise and completeAll pertinent, identifying data includedMention all people concerned, situation and signature of person making reportEasily understoodImportant points are emphasized R S MEHTA, MSND 28
Key Messages• Written policies and procedures are the backbone of the quality system• Complete quality assurance records make quality management possible• Keeping records facilitates meeting program reporting requirements29
• Records and reports revels the essential aspects of service in such logical order so that the new staff may be able to maintain continuity of service to individuals, families and communities. R S MEHTA, MSND 30
What are Electronic Medical Records?The IOM 2003 Patient Safety Report describes an EMR asencompassing: – “a longitudinal collection of electronic health information for and about persons – Immediate electronic access to person- and population- level information by authorized users; – Provision of knowledge and decision-support systems that enhance the quality, safety, and efficiency of patient care and – Support for efficient processes for health care delivery.”
What are Electronic Medical Records? The 1997 IOM report “The Computer-Based Patient Record: An Essential Technology for Health Care” defines an EMR as: “A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information.”
What are Electronic Medical Records? The American Health Information Management Association defines three essential capabilities of an EMR: 1. To capture data at the point of care, 2. To integrate data from multiple internal and external sources, and 3. To support caregiver decision making.
Implementing an EMR in LTC Leadership Support Pre- Change Peer Mentor & Go Live & AccountImplementation Management Training Support Management Optimum User Adoption & Customer ROI
Records Should be Permanent, Secure, Traceable• Permanent: • Traceable: – Sign and date every – Keep books bound record – Number pages – Use permanent ink – Control storage• Secure: – Maintain confidentiality RECORDS – Limit access – Protect from environmental hazards37
Summary• What is the difference between a document and a record?• What are some examples of documents and records?• Name examples of information not found in a manufacturer product insert.• What are some key features of SOPs?• What are some tips for good record-keeping?• How should records be maintained?• How are test site records reported in your country?38
Transfer of Patients• Transferring unit will change the status of any appropriate interventions from “Active” to “Complete” by clicking in the Status column – Completed Admissions Documentation – System Flowsheet• Receiving unit stops all nursing orders initiated in order entry, enters transfer orders according to policy and procedure, and the nurse will add on the correct system flowsheet for the patient on the intervention list using the “Add Intervention” Function
Order Entry• All paper physician order sheets must be faxed to pharmacy upon admission• Pharmacy will enter any medications and IVs into Meditech – the list of current medications can be viewed in the EMR by clicking on the Medications tab• All non-medication orders will be entered by the nurse or secretary into the Meditech order entry system
Order Entry• It is the RN’s responsibility to verify ALL orders (lab, radiology, nursing, etc.) are entered into Meditech from the Physician Order Sheet (Use Order History in the EMR)• Initial each individual order with red ink after verification that the order is in Meditech• After all orders have been entered and verified, a Kardex will be printed from the Meditech desktop using the Reports button
Verification of Physician Orders• For ancillary department orders requiring pager notification (Respiratory Therapy) the time of the page is written on the order sheet next to the order• Co-sign each set of physician orders with initials, title, date, and time
24-hour Chart Checks• Performed on 11pm – 7am shift• Review ALL orders written during the previous 24 hours and verify they are in Meditech by accessing the EMR (order history section, sorted by date)• Sign entire physician’s order sheet with name/initials, title, date and time in red ink
Blood Administration Documentation• Blood Transfusions are documented as an Intervention Set, which can be added using the “Add Intervention” link on the Intervention worklist (search for “set”)• The set is comprised of: – Blood Administration Verification (completed just prior to starting infusion) – Blood Product Infusion (start time and initial rate) – Infusion Changes (any rate changes during infusion) – Blood Product Completion (completed at end of infusion) – Blood Vital Signs (baseline vitals taken at start, then q15min x 2 after initiation, then hourly)
Documentation of Wounds• Wounds are documented as an Intervention Set, which can be added using the “Add Intervention” link on the Intervention worklist (search for “set”)• The set is comprised of: – Wound / Pressure Ulcer Status Assessment: for initial, weekly, and change of status wound documentation (more detailed) – Wound Care / Dressing Change Assessment: for daily documentation of dressing changes (focused assessment specifically for dressing changes)
Critical Lab Values Documentation• The lab will call the nurse (as well as the physician) responsible for taking care of the patient with the critical lab value• The telephonic critical result, upon receipt, will be read back to the technologist/technician and documented as having been read back. If that does not happen, the technologist/technician will request that the nurse receiving the critical result read it back.
Critical Lab Values DocumentationProcedure1. Verify the result by verbally reading the result back to the technologist/technician2. Notify the nurse assigned to the patient of the critical result if she/he was not the one to receive the telephonic notification.3. Document receiving the phone call about the critical value, the critical result, and what you did about the result on the Critical Lab Values Intervention in Meditech PCS.
Computer Downtime• In the event of a computer downtime, the documentation system reverts back to paper (all paper forms will be stocked on units)• For downtime less than 4 hours (med/surg) and 2 hours (critical care), information that is recorded on paper will need to be entered into PCS• For downtime exceeding 4 hours (med/surg) and 2 hours (critical care), the paper system will replace PCS until the end of the shift and until the system is back up – the only data that must be re-entered into PCS in this case are the Vital Signs and the I&O, so the EMR record will be accurate
Discharge Documentation• The physician writes the discharge instructions• The nurse is responsible for reviewing all instructions with the patient and obtaining the patient signature• Carenotes can be printed out from the Infoweb (click on Micromedix link to access) for patient education• The nurse should make sure the patient understands the complete list of medications the patient is to take once being discharged (compared to any medications the patient was taking on admission), as part of the medication reconciliation process• Original form goes to medical records and a copy is given to the patient upon discharge
What stays on paper?• Consent forms• Admission / Transfer Summaries• OR/Recovery Documentation• Physician Order Sheets• Documentation During Patient Codes• Pre-op Checklist• Discharge Instructions• Labor Event – Triage up until Delivery• Monitoring Strips
Documentation Details• A nurse can skip a question on an assessment if he/she is unable to assess the question due to patient condition or if the question is not applicable for the patient at that time• Any retrospective documentation can be entered up to 3 days following patient discharge. ?
Documentation Details• Changes to documentation may only be made by the person who recorded the documentation• Partially documented entries, documentation editing, and undoing documentation can be completed by clicking in the History column for the appropriate intervention
SYSTEM OF MEDICAL RECORD• DEFINITION Medical Record of the patient stores the knowledge concerning the patient and his care. It contains sufficient data written in sequence of occurrence of events to justify the diagnosis, treatment and outcome. In the modern age, Medical Record has its utility and usefulness and is a very broad based indicator of patients care.
Flow of Medical Record :-The flow chart of inpatient Medical Record is asunder :- WardsCentral AdmissionOffice Medical Record Department 1. Assembling Afetr completion of Reccords 2. ADMN. & Hospital statistics prepared Discharge Monthly/Yearly analysis 3. Storage Area Medical Record is filled for perusal of Patients/claims/research purposes.
FILING OF MEDICAL RECORDS• The inpatients Medical Record is filed by the serial numbers assigned at central Admitting Office.• The Record is bound in bundles 100 each and are kept year wise according to the serial number.RETENTION OF MEDICAL RECORD• The policy is to keep indoor patient Records for 10 years• The OPD registers for 5 years• The record which is register for legal purposes in Maintained for 10 years or till final decision at the court of Law.
TYPES OF RECORDS1. Cumulative or continuing records• This is found to be time saving, economical and also it is helpful to review the total history of an individual and evaluate the progress of a long period. (e.g.) child’s record should provide space for newborn, infant and preschool data.• The system of using one record for home and clinic services in which home visits are recorded in blue and clinic visit in red ink helps coordinate the services and saves the time. R S MEHTA, MSND 56
2. Family records• The basic unit of service is the family. All records, which relate to members of family, should be placed in a single family folder. This gives the picture of the total services and helps to give effective, economic service to the family as a whole.• Separate record forms may be needed for different types of service such as TB, maternity etc. all such individual records which relate to members of one family should be placed in a single family folder. R S MEHTA, MSND 57