Health Care Record

Documentation

• Key communication strategy in healthcare
• Produces a written account of patient data, clinical interventions, and patient responses
• Available to all members of the healthcare team
• Allows others to track a patient's clinical course

Purposes of the Health Care Record

• Facilitates interprofessional communication
• Provides a legal record of care
• Provides justification for financial billing and reimbursement of care
• Supports the process of quality and performance improvement
• Serves as a resource for education and research

Interprofessional Communication

• Legal documentation
• Reimbursement
• Auditing and monitoring
• Education
• Research

Electronic Health Record System (EHRS)

• Implemented through the Health Information Technology for Economic and Clinical Health (HITECH) Act
• Electronic health record (EHR) is an individual's lifetime computerized record
• Electronic medical record (EMR) is the record for an individual healthcare visit

Maintaining Privacy, Confidentiality, and Security

• Protected health information (PHI) must be secured
• Privacy, confidentiality, and security mechanisms include firewalls and passwords
• Procedures for handling and disposing of information are necessary

Methods of Documentation

• Documentation of patient assessment data
• Uses flow sheets, progress notes, and charting by exception

Common Record-Keeping Forms

• Admission nursing history form
• Patient care summary
• Care plans
• Discharge summary forms

Acuity Rating Systems

• Used to determine hours of care and number of staff required for a group of patients
• Patient's acuity level is based on the type and number of nursing interventions required

Documentation in the Long-Term Health Care Setting

• Governed by individual state regulations, The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS)

Case Management and Use of Critical Pathways

• Case management model incorporates an interprofessional approach to delivery and documentation of patient care
• Critical pathways are interprofessional care plans that identify patient problems, key interventions, and expected outcomes
• Variances are unexpected outcomes, unmet goals, and interventions not specified within a critical pathway

Informatics and Information Management in Health Care

• Health care information technology (HIT) is used to enhance quality and efficiency of care
• Health care information system (HIS) has two types: clinical information system and administrative information system
• Clinical information system (CIS) is an example of computerized provider order entry (CPOE)
• Nursing clinical information systems (NCIS) have two designs: nursing model and critical pathway
• Clinical decision support systems (CDSS) aid and support clinical decision making

Learn about the importance of health care records in facilitating communication among healthcare professionals, providing a legal record of care, and supporting quality and performance improvement.