Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 9 Recording and Reporting

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Medical Records

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Medical records cannot be shared among health care workers.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Medical records are a means to share information among health care workers to ensure client safety and continuity of care.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Permanent account Sharing information Quality assurance Accreditation Reimbursement Education and research Legal evidence Uses of Medical Records

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 JCAHO

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Person’s health information Care provided by health practitioners The client’s progress The plan for care Medication cycle Immunization records Components of Medical Records

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Components of Problem-Oriented Records

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Source-oriented records contain separate forms for all entities to make different entries.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Methods of Charting Narrative charting SOAP charting Focus charting PIE charting Charting by exception Computerized method

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Beneficial Disclosure

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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; s 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Documentation

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Abbreviations

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 oFirst two digits indicate hour within 24-hour period oLast two digits indicate minutes

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Documentation Time (cont’d)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Documentation Time (cont’d)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Military time is based on two 12-hour revolutions.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Military time is based on the 24-hour clock while traditional time is based on two 12-hour revolutions.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Kardex (Refer to Figure 9-8 in the textbook.)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Other Forms of Communication Change of shift reports Client assignments Team conferences Rounds Telephone calls

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A nursing Kardex is a documentation with sections for recording frequently repeated assessment data.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Nursing Kardex is a quick reference for current information about client and client care.