Chapter 9 Recording and Reporting

1. Chapter 9 Recording and Reporting

2. Medical Records • Medical records are written collections of information about a person’s health, the care provided by health practitioners, and the client’s progress • Also known as health records or client records

3. Question • Is the following statement true or false? Medical records cannot be shared among health care workers.

4. Answer False. Medical records are a means to share information among health care workers to ensure client safety and continuity of care.

5. Uses of Medical Records • Permanent account • Sharing information • Quality assurance • Accreditation • Reimbursement • Education and research • Legal evidence

6. JCAHO • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) establishes criteria reflecting high standards for institutional health care • Representatives of JCAHO periodically inspect health care agencies and determine evidence of quality care • Based on inspection, agencies are accredited

7. Components of Medical Records • Person’s health information • Care provided by health practitioners • The client’s progress • The plan for care • Medication cycle • Immunization records

8. Source-Oriented Records • Organized according to source of documented information • Contain separate forms for physicians, nurses, dietitians, physical therapists to make written entries about their specific activities in relation to client’s care • This record provides fragmented documentation

9. Problem-Oriented Records • Organized according to client’s health problems • Four major components: data base, problem list, plan of care, progress notes • Information compiled and arranged to emphasize goal-directed care; promote recording of pertinent information; facilitate communication among health care professionals

10. Components of Problem-Oriented Records

11. Question • Is the following statement true or false? Source-oriented records contain separate forms for all entities to make different entries.

12. Answer True. Source-oriented records contain separate forms for physicians, nurses, dietitians, and physical therapists to make written entries about their specific activities in relation to client’s care.

13. Methods of Charting • Narrative charting • SOAP charting • Focus charting • PIE charting • Charting by exception • Computerized method

14. Question • Which of the following charting methods involves writing information about the client and client care in chronologic order? a. SOAP b. PIE c. Narrative d. Focus

15. Answer c. Narrative charting Narrative charting involves writing information about the client and client care in chronologic order. SOAP charting involves documenting client data under four essential components. Focus charting is a modified form of SOAP charting. PIE charting is a method of recording the client’s progress under the headings of problem, intervention, and evaluation.

16. HIPAA • HIPAA legislation protects the rights of U.S. citizens to retain their health insurance • Requires health care agencies to safeguard written, spoken, and electronic health information • Health care agencies must obtain authorization from client to release information to family or friends, attorneys, or for other uses

17. HIPAA (cont’d) • Submits written notice to all clients identifying uses and disclosures of health information • Obtains client’s signature indicating knowledge of disclosure of information and right to learn who has seen his records • Limits casual access to identity of client and health information • Health agencies must ensure protection of electronic data

18. Beneficial Disclosure

19. Workplace Applications • Client names on charts no longer visible to public • All clipboards must obscure private client data, including name • Whiteboards cannot link client name with diagnosis, procedure, or treatment • Computer screens not visible to public; flat screen monitors recommended

20. Workplace Applications (cont’d) • Conversations regarding clients must occur in private places • Fax machines and medical records must be limited to areas inaccessible to public • Cover sheet on all faxes; emails warning that confidential information being transmitted • Light boxes (for x-ray, scan results) must be located in private areas • Documentation must be kept on all with access to client records

21. Aspects of Documentation • The type of information recorded • The people responsible for charting • The frequency for making entries on the record • The type of response given for the information recorded

22. Nursing Documentation

23. Abbreviations • Abbreviations shorten length of documentation and documentation time • Agencies provide list of approved abbreviations and their meanings • Use only abbreviations on agency’s approved list • Use JCAHO “Do Not Use” list to avoid and reduce medical errors

24. Common Abbreviations

25. Documentation Time • Traditional time • Two 12-hour revolutions; identified with hour and minute, followed by a.m. or p.m. • Military time • Based on 24-hour clock; uses different four-digit number for each hour and minute of the day • First two digits indicate hour within 24-hour period • Last two digits indicate minutes

26. Documentation Time (cont’d)

27. Documentation Time (cont’d)

28. Question • Is the following statement true or false? Military time is based on two 12-hour revolutions.

29. Answer False. Military time is based on the 24-hour clock while traditional time is based on two 12-hour revolutions.

30. Charting Guidelines • Should not be time-consuming to write and read • Everyone involved in the care of a client should make entries in the same location in the chart • The nurse should address specific content in charted progress notes

31. Charting Guidelines (cont’d) • Assessments should be documented on a separate form and give the client’s problems a corresponding number for quick access • Abnormal assessment findings, or care that deviates from the standard, should also be documented separately • Client information should be documented electronically • Information should always be legible

32. Charting Guidelines (cont’d) • Abbreviations and terms should be consistent with agency-approved lists • The date of the documentation should be recorded • The time of the documentation should be recorded

33. Written Forms of Communication • Nursing care plan: list of client’s problems, goals, and nursing orders for client care • Nursing Kardex: quick reference for current information about client and client care • Checklists: documentation with check mark or initials • Flow sheets: documentation with sections for recording frequently repeated assessment data

34. Nursing Kardex (Refer to Figure 9-8 in the textbook.)

35. Other Forms of Communication • Change of shift reports • Client assignments • Team conferences • Rounds • Telephone calls

36. Question • Is the following statement true or false? A nursing Kardex is a documentation with sections for recording frequently repeated assessment data.

37. Answer False. Nursing Kardex is a quick reference for current information about client and client care.