Health Care Record

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is the primary factor in determining a patient's acuity level?

The patient's diagnosis

The patient's age and medical history

The type and number of nursing interventions required by the patient over a 24-hour period (correct)

The patient's ability to perform daily living activities

Which organization governs documentation in the long-term health care setting?

The American Nurses Association

The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) (correct)

The American Medical Association

The National Institute of Nursing Research

What is the primary goal of case management in health care?

To improve patient outcomes through an interprofessional approach to delivery and documentation of patient care (correct)

To reduce the number of hospital readmissions

To increase the use of technology in healthcare

To reduce healthcare costs

What is a critical pathway?

An interprofessional care plan that identifies patient problems, key interventions, and expected outcomes within an established time frame Signup and view all the answers

What is the purpose of a clinical decision support system (CDSS)?

To aid and support clinical decision making Signup and view all the answers

What is the primary advantage of using a nursing clinical information system (NCIS)?

Better information access, better documentation quality, reduced errors of omission, reduced hospital costs, increased nurse job satisfaction, and clinical database development Signup and view all the answers

What is health care information technology (HIT) used for?

To enhance quality and efficiency of care Signup and view all the answers

What is a variance in a critical pathway?

An unexpected outcome, unmet goal, or intervention not specified within a critical pathway Signup and view all the answers

What is a clinical information system (CIS)?

An example of computerized provider order entry (CPOE) Signup and view all the answers

What is the primary goal of informatics in health care?

To enhance quality and efficiency of care Signup and view all the answers

What is the primary purpose of documentation in healthcare?

To produce a written account of patient data Signup and view all the answers

What is the main benefit of electronic health record systems (EHRS)?

They facilitate interprofessional communication and improve quality of care Signup and view all the answers

Which of the following is a type of documentation used to track patient assessment data?

Flow sheets Signup and view all the answers

What is the purpose of acuity rating systems in healthcare?

To determine the number of staff required for a group of patients Signup and view all the answers

What is protected health information (PHI)?

Individually identifiable health information Signup and view all the answers

What is the purpose of charting by exception?

To document only abnormal or significant patient data Signup and view all the answers

What is the primary purpose of an admission nursing history form?

To obtain initial patient information Signup and view all the answers

What is the purpose of a patient care summary?

To provide an overview of patient care Signup and view all the answers

What is the primary benefit of using electronic medical records (EMRs)?

They improve the quality of care by reducing errors Signup and view all the answers

What is the purpose of a care plan?

To outline patient goals and interventions Signup and view all the answers

Study Notes

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

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

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.