Nursing

• Nurses must maintain patient confidentiality and only share private health information with others if it benefits the patient.
• Effective communication among health professionals is vital to the quality of client care.
• Health personnel communicate through discussion, reports, and records.
• A discussion is an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.
• A report is oral, written, or computer-based communication intended to convey information to others.
• A record, also called a chart or client record, is a formal, legal document that provides evidence of a client's care and can be written or computer based.
• All client records have similar information.
• Recording, charting, or documenting is the process of making an entry on a client record.
• The nurse has a duty to maintain confidentiality of all patient information according to the ANA code of Ethics 2001.
• The client's record is also protected legally as a private record of the client's care.
• Access to the record is restricted to health professionals involved in giving care to the client.
• The institution or agency is the rightful owner of the client's record.
• For purposes of education and research, most agencies allow student and graduate health professionals access to client records.
• The records are used in client conferences, clinics, rounds, client studies, and written papers.
• The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence.
• Documentation is the process of making an entry on a client record.
• A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells.
• The use of exact measurements establishes accuracy in documentation.
• The information within a recorded entry or a report must be complete, containing appropriate and essential information.
• Communicate information in a logical order and it is more effective when notes are concise, clear, and to the point.
• Timely entries are essential in a patient's ongoing care.
• To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient's bedside to facilitate immediate documentation of information as it is collected from a patient.
• Document the following activities or findings at the time of occurrence: vital signs, pain assessment, administration of medications and treatments, preparation for diagnostic tests or surgery, including preoperative checklist.
• Moral decision making involves discerning which goals and means are conducive to human fulfillment and according to God's will.
• Students in health disciplines often use client records as educational tools.
• The principle of formal cooperation occurs when someone intentionally helps another person carry out a sinful act.
• A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness.
• In some jurisdictions, the record is considered inadmissible as evidence when the client objects, because information the client gives to the primary care provider is confidential.
• The principle of double effect, sometimes it is permissible to cause a harm as a side effect (or "double effect") of bringing about a good result even though it would not be permissible to cause such a harm as a means to bringing about the same good end.
• Information from records may assist health care planners to identify agency needs, such as overutilized and underutilized hospital services.
• Records can be used to establish the costs of various services and to identify those services that cost the agency money and those that generate revenue.
• Material cooperation is immediate when the object of the cooperator is the same as the object of the wrongdoer.
• The lesser evil principle and lesser-evilism, is the principle that when faced with selecting from two immoral options, the least immoral one should be chosen.
• Auditing Health Agencies involves a review of client records for quality assurance purposes.
• The client's record is a legal document and is usually admissible in court as evidence.
• The formation of a well-formed conscience must take into consideration the complementarity of faith and reason, and conscience is a unique eternal faculty enabling us by using reason to feel the difference between right and wrong.
• Documentation also helps a facility receive reimbursement from the government.
• For a facility to obtain payment through Medicare, the client's clinical record must contain the correct diagnosis related group (DRG) codes and reveal that the appropriate care has been given.
• The information contained in a record can be a valuable source of data for research.
• The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.