Health Care Record Purpose

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 Within the Medical Record

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

Electronic Health Record (EHR)

• Shift to electronic documentation
• Electronic health record system (EHRs)
• American Recovery and Reinvestment Act (ARRA) and Health Information Technology for Economic and Clinical Health (HITECH) Act
• An individual's lifetime computerized record

Electronic Medical Record (EMR)

• The record for an individual healthcare visit

Maintaining Privacy, Confidentiality, and Security

• Protected health information (PHI)
• Privacy, confidentiality, and security mechanisms
• Firewall
• Password
• Handling and disposing of information

Standards and Guidelines for Quality Nursing Documentation

• Guidelines for quality documentation
• Factual
• Accurate
• Appropriate use of abbreviations
• Current
• Organized
• Complete

Methods of Documentation

• Documentation of patient assessment data
• Flow sheets
• Progress notes
• Charting by exception

Common Record-Keeping Forms within the Electronic Health Record

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

Documenting Communication with Providers and Unique Events

• Telephone calls
• Telephone and verbal orders
• Incidence or occurrence reports

Acuity Rating Systems

• Used to determine hours of care and number of staff required for a group of patients every shift or every 24 hours
• Patient's acuity level 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)

Documentation in the Home Health Care Setting

• Medicare has specific guidelines to establish eligibility for home care reimbursement
• Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance companies
• Nurses use two different data sets to document clinical assessments and care provided in the home care setting: OASIS and Omaha system

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 within an established time frame
• Variances: unexpected outcomes, unmet goals, and interventions not specified within a critical pathway

Informatics and Information Management in Health Care

• Health care information technology (HIT) used to enhance quality and efficiency of care
• Health care information system (HIS): two types, clinical information system and administrative information system
• Clinical information system (CIS): example, computerized provider order entry (CPOE)

Nursing Clinical Information Systems (NCIS)

• Two designs: nursing model and critical pathway
• Advantages: better information access, better documentation quality, reduced errors of omission, reduced hospital costs, increased nurse job satisfaction, clinical database development

Clinical Decision Support Systems (CDSS)

• Aids and supports clinical decision making

Nursing Informatics

• Specialty area of practice
• Integrates nursing science, computer science, and information science
• Informatics competencies for nursing graduates