Chapter 26 Documentation and Informatics

1. Chapter 26Documentation and Informatics

2. Confidentiality • Nurses are legally and ethically obligated to keep client information confidential. • Nurses are responsible for protecting records from all unauthorized readers. • HIPAA act requires disclosure or requests regarding health information.

3. Standards • The Joint Commission requires each client have an assessment: • Physical, psychosocial, environment, self-care, client education, and discharge planning needs • Federal and state regulations, state statutes, standards of care, and accreditation agencies set nursing documentation standards.

4. Multidisciplinary Communication Within the Health Care Team • Records or chart: • Confidential permanent legal document • Reports: • Oral, written, audiotaped exchange of information • Consultations: • A professional caregiver providing formal advice to another caregiver • Referrals: • Arrangement for services by another care provider

5. Purposes of Records

6. Guidelines for Quality Documentation and Reporting • Factual • Accurate • Complete • Current • Organized

7. Methods of Recording • Narrative: • The traditional method • Problem-Oriented Medical Record (POMR): • Database • Problem list • Nursing care plan • Progress note

8. Methods of Recording: Progress Notes • SOAP: • Subjective, objective, assessment, plan • SOAPIE: • Subjective, objective, assessment, plan, intervention, evaluation • PIE: • Problem, intervention, evaluation • Focus Charting (DAR): • Data, action, response

9. Methods of Reporting • Source records: • A separate section for each discipline • Charting by exception (CBE): • Focuses on documenting deviations • Case management plan and critical pathways: • Incorporates a multidisciplinary approach to care

10. Common Record-Keeping Forms

11. Home Care Documentation • Medicare has specific guidelines for establishing eligibility for home care. • Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. • Nurses need to document all their services for payment.

12. Long-Term Health Care Documentation • Governmental agencies are instrumental in determining the standards and policies for documentation. • The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation. • The department of health in states governs the frequency of written nursing records.

13. Computerized Documentation • Software programs allow nurses to enter assessment data. • Computers generate nursing care plans and document care. • A complete computer-based patient care record (CPCR) is not without legal risks.

14. Reporting • Change of shift • Telephone reports • Verbal or telephone orders • Transfer reports • Incident reports