Chapter 7: HEALTH CARE RECORDS

• Nursing Documentation is a responsibility that spans across all nursing practice levels and settings
• Nursing documentation


  Provides a full account of patient care to create record of services
• Purposes of nursing documentation

  • Reimbursement
  • Ensure quality patient care and reduce errors
  • Legal system as evidence
  • Generate data for research and quality improvement initiatives
  • Provide the basis for demonstrating nursing's contributions to patient care outcomes
• Six principles of nursing documentation (ANA)


  • Documentation characteristics
  • Education and training
  • Policies and procedures
  • Protection systems
  • Documentation entries
  • Standardized terminology
• Documentation characteristics

  • Accessible
  • Accurate and relevant
  • Auditable
  • Clear, concise, comprehensive, and thoughtful
  • Legible/readable
  • Timely and sequential
  • Aligned with the nursing process
  • Retrievable on a permanent basis
• Confidentiality


  Any client information must be maintained as an obligatory secret
• The client's record is 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
• The client has rights to their own records
• Suggestions for ensuring confidentiality and security of computerized records

  • Personal password required to enter and sign off computer files
  • Never leave a computer terminal unattended
  • Do not leave client information displayed on the monitor
  • Shred all unneeded computer-generated worksheets
  • Know the 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 the server
• Medical records


  Comprehensive documents that include detailed information about a patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress, and medicines
• Purposes of medical records

  • Communication
  • Legal documentation
  • Reimbursement
  • Auditing and monitoring
  • Research
  • Education
• Communication


  Medical records allow members of the health care team to communicate about patients' needs and responses to care, clinical decision making, individual therapies, content of consultations, patient education, and discharge planning
• Relying on the chart alone is not sufficient to communicate with the physician
• Legal documentation


  The client's record is a legal document and is usually admissible in court as evidence
• Accurate documentation is one of the best defenses for legal claims associated with nursing care
• Mistakes in documentation that commonly result in malpractice


  • Failing to record pertinent health or drug information
  • Failing to record nursing action
  • Failing to record medication administration
  • Failing to record drug reaction or changes in patient's conditions
  • Incomplete or illegible records
  • Failing to document discontinued medications
• Reimbursement


  Documentation by all members of the health care team is used to determine the severity of illness, the intensity of services received, and the quality of care provided during an episode of care
• Accurate nursing documentation of services provided and supplies and equipment used in a patient's care clarifies the type of treatment a patient received and supports accurate and timely reimbursement
• Auditing


  Reviewing financial records and billing practices to ensure accuracy and compliance with regulations
• Monitoring


  Ongoing assessment of clinical processes and patient outcomes to maintain quality care and identify areas for improvement
• Researchers use patient records to gather statistical data to contribute to evidence-based nursing practice and quality health care
• Source-oriented record


  The traditional client record where each person or department makes notations in a separate section or sections of the client's chart
• Narrative charting


  Written notes that include routine care, normal findings, and client problems

  
• Narrative documentation tends to be time consuming and repetitious
• Some nurses believe that in certain situations use of narrative charting provides better detail of individual patient assessment findings and/or complex patient situations
• Five basic components of the traditional client record (source-oriented record)

  • Admission sheet
  • Physician's order sheet
  • Medical history
  • Nurse's notes
  • Special records and reports
• Problem-oriented medical record (POMR)


  A system of organizing documentation to place the primary focus on patients' individual problems
• Advantages of POMR

  • Encourages collaboration
  • The problem list in the front of the chart alerts caregivers to the client's needs and makes it easier to track the status of each problem
• Disadvantages of POMR

  • Caregivers differ in their ability to use the required charting format
  • It takes constant vigilance to maintain an up-to-date problem list
  • It is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated
• Analgesic


  Pain relief medication
• POMR(additional)

  • Data are organized by problem or diagnosis
  • Encourages collaboration
  • Problem list in the front of the chart alerts caregivers to the client's needs and makes it easier to track the status of each problem
• Disadvantages of POMR

  • Caregivers differ in their ability to use the required charting format
  • It takes constant vigilance to maintain an up-to-date problem list
  • It is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated
• Components of POMR


  • Database
  • Problem list
  • Plan of care
  • Progress notes
• Database


  Contains all available assessment information pertaining to a patient
• Problem list


  Includes a patient's physiological, psychological, social, cultural, spiritual, developmental, and environmental needs
• Plan of care


  Disciplines involved in a patient's care develop a care plan or plan of care for each problem
• Progress notes


  Chart entries made by all health professionals involved in a client's care
• Progress note formats

  • Narrative note
  • SOAP (Subjective-Objective-Assessment-Plan) note
  • PIE (Problem-Intervention-Evaluation) note
  • Focus Charting (DATA-Action-Response) note