Healthcare Documentation and Records

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Questions and Answers

What is the primary purpose of documentation in healthcare?

To provide a legal record of care

To facilitate interprofessional communication (correct)

To serve as a resource for education and research

To track a patient's clinical course

What is the difference between an Electronic Health Record (EHR) and an Electronic Medical Record (EMR)?

EHR is a record for a single healthcare visit, while EMR is a lifetime record

EHR is a paper record, while EMR is a digital record

EHR is a lifetime record, while EMR is a record for a single healthcare visit (correct)

EHR is a digital record, while EMR is a paper record

What is the purpose of the Health Information Technology for Economic and Clinical Health Act (HITECH)?

To improve the quality of nursing documentation

To reduce the cost of healthcare

To improve patient safety

To promote the use of electronic health records (correct)

What is protected health information (PHI)?

Any information related to a patient's health Signup and view all the answers

What is the purpose of an acuity rating system?

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

What is the purpose of charting by exception?

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

What is the purpose of a care plan?

To outline a patient's treatment plan Signup and view all the answers

What is the purpose of documenting communication with providers and unique events?

To document telephone calls and verbal orders Signup and view all the answers

What is the purpose of an admission nursing history form?

To document a patient's admission data Signup and view all the answers

What is the purpose of standards and guidelines for quality nursing documentation?

To ensure accuracy and completeness of documentation Signup and view all the answers

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

Type and number of nursing interventions required over a 24-hour period Signup and view all the answers

What is the primary purpose of documentation in the long-term health care setting?

To provide quality control and justification for reimbursement Signup and view all the answers

What is the primary purpose of OASIS in the home health care setting?

To document clinical assessments and care provided in the home care setting Signup and view all the answers

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

To incorporate an interprofessional approach to delivery and documentation of patient care Signup and view all the answers

What is the primary purpose of critical pathways in health care?

To identify patient problems, key interventions, and expected outcomes within an established time frame Signup and view all the answers

What is the primary purpose of health care information technology (HIT)?

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

What is the primary function of a clinical information system (CIS)?

To document clinical assessments and care provided Signup and view all the answers

What is the primary advantage of nursing clinical information systems (NCIS)?

Better information access and reduced errors of omission Signup and view all the answers

What is the primary function of clinical decision support systems (CDSS)?

To support clinical decision making Signup and view all the answers

What is the primary focus of nursing informatics?

Nursing science, computer science, and information science Signup and view all the answers

Study Notes

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

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Description

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.