Documenting, Reporting, Conferring, and Using Informatics Dr. James Pelletier The Swain Department of Nursing The Citadel

Purposes of Patient Records Communication Diagnostic and therapeutic orders Care planning Quality process and performance improvement Research; decision analysis Education Credentialing, regulation, and legislation Reimbursement Legal and historical documentation

Characteristics of Effective Documentation Consistent with professional and agency standards Complete Accurate Concise Factual Organized and timely Legally prudent Confidential

Documentation Guidelines Goal: Complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document. - Content - Timing - Format - Accountability - Confidentiality Review Box 16-1 on page 342 of your text

Using the 24-hr Cycle Military Clock for Documenting Times

What Is Confidential? All information about patients written on paper, spoken aloud, saved on computer Name, address, phone, fax, social security number (any patient identifier) Reason the person is sick Treatments patient receives Information about past health conditions

Take note! There have been reports of school suspensions for nursing and medical students who unprofessionally share patient experiences on Facebook, blogs, and YouTube. What may start as a prank may lead to your suspension or dismissal.

Potential Breaches in Patient Confidentiality Displaying information on a public screen Sending confidential messages via public networks Sharing printers among units with differing functions Discarding copies of patient information in trash cans Holding conversations that can be overheard Faxing confidential information to unauthorized persons Sending confidential messages overheard on pagers

Patient Rights Patients have the right to: See and copy their health record Update their health record Get a list of disclosures Request a restriction on certain uses or disclosures Choose how to receive health information

Policy for Receiving Verbal Orders in an Emergency Record the orders in patient’s medical record. Read back the order to verify accuracy. Date and note the time orders were issued in emergency. Record verbal order and name of the physician issuing the order, followed by nurse’s name and initials.

Policy for Physician Review of Verbal Orders Review orders for accuracy. Sign orders with name, title, and pager number. Date and note time orders signed.

Duties of RN Receiving Telephone Orders Record the orders in patient’s medical record. Read orders back to practitioner to verify accuracy. Date and note the time orders were issued. Record telephone orders, and full name and title of physician or nurse practitioner who issued orders. Sign the orders with name and title.

Purposes of Recording Data Facilitate patient care Serve as a financial and legal record Help in clinical research Support decision analysis

The Health Insurance Portability and Accountability Act of 1996 Authorization Rule If a health institution wants to release a patient’s health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. - Permitted Disclosure of PHI - Incidental Disclosure of PHI

Permitted Disclosure of PHI While the authorization rule covers most situations in which patient information is released for purposes other than treatment, payment, and routine health care operations, there are some exceptions to the authorization rule for the good of the general population. - Public health activities - Law enforcement and judicial proceedings - Deceased people

Public Health Activities Tracking and notification of disease outbreaks Infection control Statistics related to dangerous problems with drugs or medical equipment

Law Enforcement and Judicial Proceedings Medical records crucial to the investigation and prosecution of a crime Medical records to identify victims of crime or disasters Medical personnel reporting incidents of child abuse, neglect, or domestic violence Medical records released according to a valid subpoena

Deceased People PHI needed by coroners, medical examiners, and funeral directors PHI needed to facilitate organ donations PHI provided to law enforcement in the case of a death from a potential crime

Incidental Disclosure of PHI Incidental disclosure of PHI is defined as a secondary disclosure that cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permit- ted use or disclosure of PHI. - Use of sign-in sheets - The possibility of a confidential conversation being overheard - Placing patient charts outside exam rooms - Use of white boards - X-ray light boards that can be seen by passers-by - Calling out names in the waiting room - Leaving appointment reminder voic messages

Benefits of a Health Information Exchange Provides a vehicle for improving quality and safety of patient care Provides a basic level of interoperability among EHRs maintained by individual physicians and organizations Stimulates consumer education and patients' involvement in their own health care Helps public health officials meet their commitment to the community

Benefits of a Health Information Exchange (cont.) Creates a potential loop for feedback between health-related research and actual practice Facilitates efficient deployment of emerging technology and health care services Provides the backbone of technical infrastructure for leverage by national and state-level initiatives

Methods of Documentation Source-oriented records- a paper format in which each health care group keeps data on its own separate form. Problem-oriented medical records- is organized around a patient’s problems rather than around sources of information. With POMRs, all health care profes- sionals record information on the same forms. PIE charting (problem, intervention, evaluation)- The plan of care is incorporated into the progress notes, which identify problems by num- ber (in the order they are identified).

Methods of Documentation (continued) Focus charting- Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a patient and patient care. The focus might be a patient strength, problem, or need. Charting by exception- is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or “exceptions” to these standards are documented in narrative notes. Case management model- promotes collaboration, communication, and teamwork among caregivers; makes efficient use of time; and increases quality by focusing care on carefully developed outcomes.

Formats for Nursing Documentation Initial nursing assessment Care plan; patient care summary Critical collaborative pathways Progress notes Flow sheets and graphic records Medication record Acuity record Discharge and transfer summary Long-term care documentation

Types of Flow Sheets Graphic record 24-hour fluid balance record Medication record 24-hour patient care records and acuity charting forms

Benefits of Nursing Informatics Increases in the accuracy and completeness of nursing documentation Improvement in the nurse’s workflow and an elimination of redundant documentation Automation of the collection and reuse of nursing data Facilitation of the analysis of clinical data