Other Sources of Client

• Client's Data

  medical information held about an individual patient

  include information relating to their past and current health or illness, their treatment history, lifestyle choices and genetic data.
• the patient is the primary source of data collection in health assessment


  Primary Source of Data
• data include information from the patient's chart, family members, or other health care team members


  Secondary Sources of Data
• Prevents fragmentation, repetition and delays in client care as it is used by health care professionals in communicated with each other and with the client.

  Communication
• Client records are kept for several purposes, including communication, planning client care, auditing health agencies, research, education, reimbursement, legal documentation, and health care analysis.


  Planning Client Care
• Review client records for quality assurance to determine if the hospital is meeting its stated standards


  Auditing Health Agencies
• Data in the record can be used for nursing research.

  Treatment plans for several clients with the same health problems can yield information helpful in treating other clients.

  Research
• Client records may use data as educational tools


  Education
• Client's records serve as evidence in court.

  Admissible in court as evidence unless client objects because information client gives to primary care provider is confidential

  Legal Document
• Records may help health care planners identify agency needs, such as overuse or underuse of hospital services.


  Health Care Analysis
• Filled out by the patient on their first visit to the doctor’s office and updated as needed.

  It contains information that is directly related to the patient, such as their last name, first name, gender, DOB, marital status, address, telephone number, employment status, employer’s address and phone number, and name and contact information for the person who is responsible for them.


  Patient Demographics
• • Assignment of benefits: the patient or guarantor authorizes their health insurance company to make payments directly to the physician, medical practice, or hospital for the treatment received.
  • Insurance information includes Insurance payer's name, address, and phone number, Subscriber name, Policy number, Responsible party name, address, and phone number, Responsible party employer, occupation, and employer phone number Patient's relationship with the insured

  Financial Information
• Consent


  A signed statement from the patient or guardian approving the course of treatment
• Consent/Authorization Forms


  • Physician must disclose as much information as possible so the patient may make an informed decision about his/her care
  • Needs to include: Diagnosis and chances of recovery, Recommended course of treatment, Risks and benefits involved in the treatment, Risks if no treatment is taken, Probability of success if treatment is taken, Recovery challenges and length of time
• Things to be discussed before signing the forms

  • Risks and benefits involved in the treatment
  • Risks if no treatment is taken
  • Probability of success if treatment is taken
  • Recovery challenges and length of time
• Release of Information

  Consent and Authorization Forms
• Release of Information 


  Need to bring:

  A valid authorization to release protected health information.

  Identity verification such as a driver’s license.

  A description of the information to be used or disclosed.

  The name of the person or organization authorized to disclose the information.

  The name of the person or organization authorized to disclose the information, and the information is to disclose.

  An example of this are the birth certificates to be claimed and death certificated as well.
• Release of Information


  Need to bring:

  1. A valid authorization to release protected health information. Identity verification such as a driver’s license.
  2. A description of the information to be used or disclosed.
  3. The name of the person or organization authorized to disclose the information.
  4. The name of the person or organization authorized to disclose the information, and the information is to disclose.
  5. An example of this are the birth certificates to be claimed and death certificated as well.
• JCAHO 


  The Joint Commission (formerly known as Joint Commission on Accreditation of Healthcare Organization) is the peer review organization which provides the primary review of hospitals and healthcare providers.

  “Requires client record to be timely, complete, accurate, confidential and specific to the client.”
• ANA Code of Ethics


  The American Nurses Association Code of Ethics was developed as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.

  “ . . . the nurse has a duty to maintain confidentiality of all patient information.”
• Code of Ethics for Filipino Nurses


  The Code of Ethics for Filipino Nurses outlines ethical principles and guidelines for registered nurses in their interactions with people, practice, co-workers, society, environment, and the nursing profession.

  “Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing accountability.”
• HIPAA


  The Health Insurance Portability and Accountability Act of 1996 is a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed.
• Ensuring confidentiality of computer records:

  Personal password that is not to be shared

  Never leave a computer terminal unattended after logging on

  Do not leave client information displayed on the monitor where others may see it

  Shred all unneeded computer-generated worksheets

  Know facility's policy and procedure for correcting an entry error

  Follow agency procedures for documenting sensitive material

  IT personnel must install a firewall to protect server from unauthorized access
• Confidentiality and privacy of all patient information is needed.

  Client's record protected legally as a private record of client's care

  Responsibility in using records for the purpose of education and research
• Medical History (Treatment)


  Outlines any medical ailments the patient has had in the past and present
• Physical Examination (PE)


  • Complete head-to-toe evaluation of the patient's physical state
• Medical History includes

  • Chief Complaint
  • History of illness (present and past)
  • Vital signs
  • Physical examination
  • Surgical history (for patients who had surgery)
  • Obstetric history (for pregnant women)
  • Allergies
  • Family history
  • Immunization history (for pediatric clients)
  • Habits such as exercise, diet, smoking, alcohol intake and drug use/abuse (when necessary)
  • Developmental history (for pediatric patients)
• Doctors Order Sheet


  Physician's orders for the patient to receive testing, procedures, or surgery including directions to other treatment team members
• Prescriptions


  For medications and medical supplies or equipment for the patient's home use
• Findings


  Opinions from consulting physicians
• Nursing Records


  In these records, vital indicators including blood pressure, temperature, pulse, respiration, intake, output, etc of the patient are recorded.

  Nurse’s notes include documentation separate from the physician including Assessment, Nursing Diagnosis, Planning, Intervention, & Evaluation.

  Medication List - Prescribed medication including dose, method of intake, and schedule.

  Progress Notes - include new information and changes during patient treatment.
• Diagnostic Procedures and Laboratory Results 


  These comprise documents containing the findings of every diagnostic test and laboratory procedure that the patient underwent.

  The findings or outcomes of samples taken from the patient, such as bone marrow, blood, or tissue, are documented in the pathology report. Record of findings from radiology testing, Ultrasound, ECG.
• Operative and Anesthesiology Report


  Surgeon’s written account of the process, including the preoperative and postoperative diagnoses, the precise specifics of the surgical procedure, the patient’s response to it, and any complications that may have arisen.

  Information from the attending anesthesiologist or anesthetist that provides a thorough account of anesthesia during surgery, including the drugs used, their dosage and administration time, the patient’s reaction, the monitoring of vital signs, how well the patient tolerated the anesthesia, and any complications that may have arisen
• Discharge Summary


  A summary of the patient’s hospital care, including the date of admission, the diagnosis, the course of treatment and any responses from the patient, the outcomes of the tests, the final diagnosis, the follow-up plans, and the date of discharge.
• Nurse's Responsibility


  Ensure that records are accurate and complete to effectively manage the client and allow for good communication between the nurse and other healthcare members.

  Keeping good nursing records allows for identifying problems that have arisen and the action is taken to rectify them.
• Nursing records


  • Clear and accurate
  • Endorsement to the next shift of nurses will be incomplete without them
• Quality of record-keeping


  Can be a good (or bad) reflection of the standard of care given to patients
• Careful, neat, and accurate patient records


  • Hallmarks of a caring and responsible nurse
• Poorly written records


  Can lead to doubts about the quality of a nurse's work
• Poor record-keeping can mean negligence, even if provided the correct care - and this may cause you to lose your right to practice