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33 Cards in this Set
- Front
- Back
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Documentation
The (accreditation agencies) Joint Commission sets specific guidelines for ___. |
anything written or printed you rely on as record or proof for authorized persons. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Shows level of quality of care delivered.
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HIPAA
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Previously the rule required written consent for disclosure of all client info. Under new regulations, in order to eliminate barriers that could delay access to care, providers are required only to notify clients of their privacy policy and make a REASONABLE effort to get written acknowledgment of this notification.
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In addition, providers must obtain separate client authorization for disclosure of . . .
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drug and alcohol treatment, mental health, and HIV info, as well as for health care purposes. Clients have rights to request restrictions on the uses and disclosures of their info.
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People can file a complaint (if privacy protection is violated) w/ covered provider or health plan or w/ USDHHS.
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Providing Recourse
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Standards
TJC - stress importance of evaluating client outcomes, even a multidisciplinary care plan. IE pain management |
Current TJC standards require that all clients who are admitted to a health care institution have an assessment of physical, psychosocial, environmental, self-care, client education, and discharge planning needs. TJC requires documentation w/in the context of nursing process, as well as evidence of client & family teaching and discharge planning.
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Federal and state regulations, state statutes, standards of care, and accrediting agencies set nursing documentation standards. ie ANA
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The nursing service dept of ea. health care agency selects a method for documenting client care.
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Reports - oral, written, or audiotaped exchanges of info btwn caregivers. Change of shifts, telephone reports, transfer reports, and incident reports. Consultation - discussion whereby one professional caregiver gives professional advice about care of a client to another caregiver.
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Nurses document referrals, consultations and conferences on clients permanent record.
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While caring for any client, first refer to the medical record for relevant assessment findings.
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Review this first, then conduct own individualized client assessment.
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Nurses Service Organization (medical malpractice, professional liability, and risk management company)
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identified common charting mistakes that can result in malpractice. Failures to: (write legibly, record given medications or medications discontinued, reactions to medication, pertinent health info, failure to record nursing actions)
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DRGs
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prospective payment system. Hospitals reimbursed by Medicare for ea DRG. Documentation helps clarify type of treatment client receives and help support the reimbursement to health care agency. Notes supplies and equipment used.
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TJC requires hospitals to establish QI programs. TJC also has standards for info located in client's record, including indications that a plan of care is developed w/ client participant and that discharge planning and client education has occurred.
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TJC also asks institutions to establish standards for quality care. Nurses check to make sure QI standards are met.
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Quality Documentation and Reporting
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1. Factual 2. Complete 3. Accurate 4. Current 5. Organized
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Methods of Recording
Problem- Oriented Medical Record |
Database, Problem List, Nursing Care Plan, Progress Notes
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Progress Notes of POMR
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PIE - nursing origin, does not include assessment info, simplifies documentation by unifying care plan and progress notes, daily assessment appear on flow sheets to avoid duplication, PIE #s according to client's problem
SOAP -originated from medical records |
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Progress Notes of POMR part 2
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Focus Charting - 3rd narrative format which involves DAR notes. Data both Subjective and Objective. A - action or nursing intervention. R - response of client (evaluation of effectiveness), doesn't chart only problems but also client's concerns
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Source Record
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Client's chart has a separate section for ea discipline (nursing, medicine, social work) to record data. Problem - details about a specific problem are distributed throughout the record. Does not show how info from the disciplines is related or how care is coordinated to meet all of the client's needs.
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Charting By Exception
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focuses on documenting deviations from the established norm or abnormal findings. Reduces documentation time and highlights trends or changes in client's condition. Shorthand method for documenting normal findings and routine care based on CLEARLY DEFINED STANDARDS OF PRACTICE and predetermined criteria for nursing assessments and interventions. only documents SIGNIFICANT findings or exceptions to predefined norms. Can pose legal risks if nurses are not disciplined in documenting exceptions.
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Case Management model of delivering care incorporates a multidisciplinary approach to documenting client care. Many org., standardized plan of care is summarized into critical pathways for a specific disease or condition.
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Critical Pathways are multidisciplinary care plans that include client problems, key interventions, and expected outcomes w/in an established time frame. Critical pathways eliminate nurses' notes, flow sheets, and nursing care plans because the pathway document integrates all relevant info.
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Variances - unexpected outcomes, unmet goals, and interventions not specified w/in the critical pathway time frame are called variances.
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Positive variance is when client progresses more rapidly than expected.
Variance analysis is necessary to review data for trends and for developing and implementing an action plan to respond to the identified client problems. |
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Categories w/in a form are usually derived fr. institutional standards of practice or guidelines established by accrediting agencies.
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Common Record Keeping Forms
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Flow Sheets
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forms that allow nurses to quickly and easily enter assessment data about the client, including vital signs and routine repetitive care, such as hygiene measures, ambulation, meals, weights, and safety restrain checks. Focus Note - unusual or changes that are significant; complete focus assessment and record this, as well as action taken, in the progress notes. Provide quick and easy reference for health care team members in assessing client's status. Critical care and acute care units.
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Kardex - (part of client care summary)
kept at nurse's station, a portable "flip'over" file or notebook. activity and treatment section and a nursing care plan section that organize info for quick reference as nurses give change-of -shift reports or make walking rounds |
Updated Kardex eliminates need for repeated referral to the chart for routine info. throughout the day. Entries in pencil.
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Acuity Records offer a way to determine the hours of care and staff required for a given group of clients.
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Based on type and # of nursing interventions required over a 24- hour period. Acuity level rates clients in comparison w/ one another.
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Standardized Care plans -some institutions have made these for nurses based on inst. standards of nursing practice, are pre-printed, established guidelines.
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Nurses modify to individualize plan in ink. Nurse is STILL responsible for an individualized approach to care.
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Discharge Summary Forms
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TJC requirements (p398-399)
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Home Care documentation is both the control and justification for reimbursement from Medicare (very specific), Medicaid, or private insurance companies. Nurses need to document all their services for payment.
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Long term care facilities - residents. The Omnibus Budget Reconciliation Act of 1987 includes extremely significant Medicare and Medicaid legislation for long-term care documentation. Looks holistically using RAI. States govern frequency of written nursing records of residents.
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Information is data that has been interpreted. Ex. When a nurse's observation of a wound's edges, color of drainage, and measurement of the wound's length. When nurse examines data over a period of time to see that the wound is not healing (information).
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Knowledge is the synthesis of info derived from several sources to produce a single concept. Based on evidence available in the scientific lit., the nurse applies the knowledge of wound care principles and intervenes to manage the client's wound
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3 purposes of medical records. 1. Education 2. Research 3. Communication
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Information Technology - refers to the management and processing of info, generally w/ assistance of computers.
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Health care information system has two types of systems: Clinical info systems, admin. info systems.
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Nursing Informatics - Supports way that nurses fx and work by providing nurses the flexibility to use the system to view data and collect info, provide client care, and document the client's condition and care provided. Supports and enhances nursing practice through improved access to info and clinical decision-making tools.
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Competence in informatics - must be able to use evolving methods of discovering, retrieving, and using info in your practice.
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NISystems -2 designs - 1. nursing process design is the most traditional. More advanced - NANDA - international nursing diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification are incorporated into software program
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Advantages of a Nursing Info system: Increased time w/ client, reduced errors of omission, reduced hospital costs, increased nurse job satisfaction, compliance w/ TJC and other accrediting agencies, development of a common clinical database and more
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NISystems 2nd Design -(critical pathway design or protocol), offers a multidisciplinary format to managing info. All health care providers use a protocol system to document care they provide clients.
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HIPPA regulations called for establishment of an electronic client records system and privacy rules to legally protect PHI (under security mechanisms of NIS)
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Clinical Information Systems- clinician, nurses, physicians, social worker, etc. Monitoring systems, order entry systems, laboratory radiology and pharmacy systems.
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Electronic Health Record - longitudinal electronic record of client health info. generated by one or more encounters in any care delivery setting.
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Healthcare Information and Management Systems Society has developed a definitional model for an EHR. Model outlines the definitions, attributes, and requirements for assessing the extent to wh/ an organization is using an EHR.
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