Chapter 26 Documentation and Informatics

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Chapter 26Documentation and Informatics
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Confidentiality

• Nurses are legally and ethically obligated to
  keep client information confidential.
• Nurses are responsible for protecting records
  from all unauthorized readers.
• HIPAA act requires disclosure or requests
  regarding health information.

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Standards

• The Joint Commission requires each client have an
  assessment
• Physical, psychosocial, environment, self-care,
  client education, and discharge planning needs
• Federal and state regulations, state statutes,
  standards of care, and accreditation agencies set
  nursing documentation standards.

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Multidisciplinary Communication Within the Health
Care Team

• Records or chart
• Confidential permanent legal document
• Reports
• Oral, written, audiotaped exchange of information
• Consultations
• A professional caregiver providing formal advice
  to another caregiver
• Referrals
• Arrangement for services by another care provider

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Purposes of Records
Communication Legal documentation
Financial billing Education
Research Auditing/monitoring
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Guidelines for Quality Documentation and Reporting

• Factual
• Accurate
• Complete
• Current
• Organized

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Methods of Recording

• Narrative
• The traditional method
• Problem-Oriented Medical Record (POMR)
• Database
• Problem list
• Nursing care plan
• Progress note

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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

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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
• Incorporates a multidisciplinary approach to care

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Common Record-Keeping Forms
Admission nursing history form Flow sheets and graphic records
Client care summary or Kardex Acuity records
Standardized care plans Discharge summary form
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Home Care Documentation

• Medicare has specific guidelines for establishing
  eligibility for home care.
• Documentation is the quality control and
  justification for reimbursement from Medicare,
  Medicaid, or private insurance.
• Nurses need to document all their services for
  payment.

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Long-Term Health Care Documentation

• Governmental agencies are instrumental in
  determining the 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.

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Computerized Documentation

• Software programs allow nurses to enter
  assessment data.
• Computers generate nursing care plans and
  document care.
• A complete computer-based patient care record
  (CPCR) is not without legal risks.

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Reporting

• Change of shift
• Telephone reports
• Verbal or telephone orders
• Transfer reports
• Incident reports