Healthcare Documentation and Records

Informatics and Documentation

• Documentation is a key communication strategy in healthcare, producing a written account of patient data, clinical interventions, and patient responses.
• It is available to all members of the healthcare team, allowing 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, including diagnosis-related groups
• Auditing and monitoring
• Education
• Research
• Shift to electronic documentation, including electronic health record systems (EHRS) and electronic health records (EHRs)
• Electronic medical records (EMRs) are used for individual healthcare visits

Maintaining Privacy, Confidentiality, and Security

• Protected health information (PHI) must be maintained
• Privacy, confidentiality, and security mechanisms, including firewalls and passwords, are used
• Procedures for handling and disposing of information, including policies for fax machine use, are in place

Standards and Guidelines for Quality Nursing Documentation

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

Methods of Documentation

• Documentation of patient assessment data, including:
  • 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
• Patient's acuity level is based on the type and number of nursing interventions required over a 24-hour period

Documentation in Specialized Settings

• Long-term health care: governed by individual state regulations, The Joint Commission, and Centers for Medicare and Medicaid Services
• Home health care: documentation is used for quality control and reimbursement from Medicare, Medicaid, or private insurance companies
• Case management and critical pathways: used to identify patient problems, key interventions, and expected outcomes within an established time frame

Informatics and Information Management in Health Care

• Health care information technology (HIT) is used to enhance quality and efficiency of care
• Health care information systems (HIS) include clinical information systems (CIS) and administrative information systems
• Nursing clinical information systems (NCIS) are designed using nursing models and critical pathways
• Clinical decision support systems (CDSS) aid and support clinical decision making
• Nursing informatics integrates nursing science, computer science, and information science to support healthcare practice

This quiz covers the importance of documentation in healthcare, including its role in communication, legal records, and financial billing. Learn about the purposes of healthcare records and their significance in patient care.