report and documentation

• a discussion is an informal oral consideration of a subject by two or more healthcare 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.
• the process on making an entry on a client record is called recording, charting, or documenting
• EHR - Electronic Health Record
• ANA - American Nurses Association
• the American Nurses Association Code of Ethics was revised in 2015.

  provision 3 states "the nurse promotes, advocates for, and protects the rights, health, and safety of the patient"

  this provision focuses on confidentiality.

  it is imperative in nursing that any client information be maintained as an obligatory secret.
• the institution or agency is the rightful owner of the client's record.
• PHI - Protected Health Information
• HIPAA - Health Insurance Portability and Accountability Act of 1996
• PHI is identifiable information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about clients, and written communications
• in communication, the record serves as the vehicle by which different health professionals who interact with a client communicate with each other
• each health professional uses data from the client's record to plan care for that client
• an audit is a review of client records for quality assurance purposes
• accrediting agencies such as the Joint Commission may review client records to determine if a particular health agency is meeting its stated standards
• the information contained in a record can be a valuable source of data for research
• students in health discipline often use client records as educational tools
• 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
• documentation also help a facility receive reimbursement from the federal government
• the client's record is a legal document and is usually admissible in court as evidence
• information from records may assist healthcare planners to identify agency needs, such as overutilized and underutilized hospital services
• records can be used to establish the cost of various services and to identify those services that cost the agency money and those that generate revenue
• Documentation System:

  1. source oriented record
  2. problem-oriented medical record
  3. PIE
  4. focus charting
  5. charting by exception
  6. computerized documentation
  7. case management
• the documentation system can be implemented using the traditional paper forms or with EHRs
• the traditional client record is source-oriented record
• in source-oriented record each healthcare provider or department makes notations in a separate section or sections of the client's chart
• in source-oriented record, information about a particular problem is distributed throughout the record
• narrative charting is a traditional part of the source-oriented record
• the narrative charting consists of written notes that include routine care, normal findings, and client problems
• in narrative charting, there is no right or wrong order to the information, although chronologic order is frequently used
• narrative recording is being replaced by other systems, such as charting by exception and focus charting
• narrative charting is used when describing abnormal findings
• source-oriented records are convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information specific to one's discipline
• in the problem-oriented medical record or problem-oriented record, the data are arranged according to the problems the client has rather than the source of the information
• the four basic component of POMR

  1. database
  2. problem list
  3. plan of care
  4. progress note