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Questions and Answers
What is the primary factor in determining a patient's acuity level?
What is the primary factor in determining a patient's acuity level?
Which organization is responsible for governing documentation in the long-term health care setting?
Which organization is responsible for governing documentation in the long-term health care setting?
What is the primary purpose of documentation in the home health care setting?
What is the primary purpose of documentation in the home health care setting?
What is the primary goal of case management in health care?
What is the primary goal of case management in health care?
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What are variances in critical pathways?
What are variances in critical pathways?
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What is the primary purpose of health care information technology (HIT)?
What is the primary purpose of health care information technology (HIT)?
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What is the primary advantage of nursing clinical information systems (NCIS)?
What is the primary advantage of nursing clinical information systems (NCIS)?
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What is the primary function of clinical decision support systems (CDSS)?
What is the primary function of clinical decision support systems (CDSS)?
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What is the primary focus of nursing informatics?
What is the primary focus of nursing informatics?
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What is the primary benefit of using OASIS in home health care settings?
What is the primary benefit of using OASIS in home health care settings?
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What is the primary purpose of documentation in healthcare?
What is the primary purpose of documentation in healthcare?
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What is the primary goal of the Health Information Technology for Economic and Clinical Health (HITECH) Act?
What is the primary goal of the Health Information Technology for Economic and Clinical Health (HITECH) Act?
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What is the main difference between an electronic health record (EHR) and an electronic medical record (EMR)?
What is the main difference between an electronic health record (EHR) and an electronic medical record (EMR)?
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What is the term for protecting sensitive health information?
What is the term for protecting sensitive health information?
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What is the primary purpose of acuity rating systems in healthcare?
What is the primary purpose of acuity rating systems in healthcare?
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What is the primary purpose of documenting patient assessment data?
What is the primary purpose of documenting patient assessment data?
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What is the primary goal of maintaining privacy, confidentiality, and security of the health care record?
What is the primary goal of maintaining privacy, confidentiality, and security of the health care record?
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What is the main purpose of charting by exception?
What is the main purpose of charting by exception?
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What is the primary purpose of documenting telephone calls and verbal orders?
What is the primary purpose of documenting telephone calls and verbal orders?
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What is the primary goal of using standards and guidelines for quality nursing documentation?
What is the primary goal of using standards and guidelines for quality nursing documentation?
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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 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
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Description
This quiz covers the importance of healthcare records in facilitating communication, providing legal documentation, and supporting quality improvement. Learn about the key purposes of healthcare records and their role in patient care.
