Medical Records: EMRs and Paper Charts

• Chart forms contain client information, directives, history, orders, progress notes, assessments, care plans, graphic data, nursing notes, medication records, lab results, discharge plans, and teaching summaries.

Electronic Medical Records (EMR)

• EMRs store forms on a computerized hard drive.
• The American Recovery and Reinvestment Act mandates computerized records for Medicare and Medicaid clients to receive payments.
• According to the CDC, around 90% of physicians use electronic health records (EHRs) as of 2019.

Paper Charts

• Hard copy paper forms are organized in a binder or folder.
• The forms are often color-coded or separated by tabbed sheets.
• EHRs are replacing paper charts.
• EHRs are accessed with a password and form selection.
• EHRs can be printed for a hard copy.
• All health care personnel contribute to medical records through charting, recording, or documenting.

Uses for Medical Records

• Medical records provide a means to share client information among health care providers.
• They ensure client safety and continuity of care.
• They can be used for quality of care investigations, accreditation compliance, reimbursement from insurance companies, health education, research, and evidence in malpractice lawsuits.

Permanent Account

• A client's medical record is a written, chronologic account of an illness or injury and care provided.
• The record is stored for future reference.
• Previous records are often requested during subsequent admissions to review health history.

Sharing Information

• Medical records facilitate communication among health care providers to help document client status and care plans.
• Sharing information prevents duplication of care, reduces the chance of error or omission, ensures correct and timely medication administration, and maintains immunization records.

Quality Assurance

• Medical records are used for quality assurance (QA), continuous quality improvement (CQI), or total quality improvement (TQI).
• This involves internal self-improvement processes to ensure care standards.
• QA methods investigate documentation in medical records and recommend corrective measures if standards are not met.

Accreditation

• The Joint Commission (TJC) sets high standards for client safety and health care quality.
• TJC and other accreditation agencies regularly inspect health care agencies to assess quality of care.
• Nursing documentation for accreditation includes initial assessments, nursing diagnoses, planned interventions, nursing care provided, and client response.
• Substandard documentation may lead to withheld or withdrawn accreditation.

Reimbursement

• Third-party payers, such as Medicare, Medicaid, and private insurers, are billed for most hospital and home care costs.
• Auditors survey records (inspectors who examine client records) to determine if care meets established reimbursement criteria.
• Undocumented, incomplete, or inconsistent documentation may result in denial of payment.

Education and Research

• Medical records provide a valuable supplement to published references for health education and research.
• Client records can facilitate research when participants are limited, requiring formal permission to protect confidentiality.

Legal Evidence

• Medical records are legal documents that must follow legally defensible criteria.
• Records may be subpoenaed as evidence in malpractice cases.
• When charting, nurses should ensure the client's name appears on each page, never chart for someone else, use specified ink, date and time each entry, chart after providing care, make entries in order, identify out-of-sequence documentation, write legibly, use correct grammar, reflect plan of care, describe outcomes, record details, use approved abbreviations, and avoid obliterations.
• Record facts, not interpretations, quote clients, indicate duplicate documentation, do not imply criticism, document physician notifications and recommendations, identify teaching information provided, leave no spaces, and sign each entry with name and title.

Client Access to Records

• Clients have the right to see their medical and billing records.
• They can request changes to inaccuracies and must be informed of who has accessed their records due to HIPAA.
• The 2022 HIPAA update includes changes to privacy practices, PHI protection, disclosures for care coordination, emergency disclosures, citizen access rights, and fees for accessing PHI.

Types of Client Records

• Client records are typically organized as source-oriented or problem-oriented.

Source-Oriented Records

• Source-oriented records organize information by the source of documentation like entries from physicians, nurses, and therapists.
• A limitation of source-oriented records is that demonstrating a unified approach to resolving client problems can be difficult.

Problem-Oriented Records

• Problem-oriented records are organized by the client's health problems.
• Problem-oriented records include a database, problem list, care plan, and progress notes.
• They help facilitate communication between health providers.

Methods of Charting

• Common methods include narrative, SOAP, focus, PIE charting, charting by exception, and electronic charting.

Narrative Charting

• Narrative charting involves writing information about the client and their care in chronologic order.
• There is no established format for narrative notations.
• Narrative charting can be time-consuming.

SOAP Charting

• S = subjective data
• O = objective data
• A = analysis of the data
• P = plan for care

SOAPIE/SOAPIER Charting

• SOAP format to SOAPIE or SOAPIER (I = interventions, E = evaluation, R = revision to the plan of care)
• Helps demonstrate interdisciplinary cooperation because care providers make entries in the same location.

Focus Charting

• Focus charting uses the word "focus" rather than "problem."
• Focus charting follows a DAR model: D = data, A = action, R = response.
• DAR notations tend to reflect the steps in the nursing process.

PIE Charting

• PIE charting records progress under headings of problem, intervention, and evaluation.

Charting by Exception

• Nurses chart only abnormal assessment findings or extraordinary care.
• proponents say that Charting by exception is a more efficient method.

Electronic Charting

• Is a component of informatics
• Informatics refers to the collection, storage, retrieval, and sharing of recorded data Most efficient for nurses when done at the point of care (POC. Computerized electronic charting advantages:
• The information is always legible
• Entries are automatically credited to the userr
• Computerized documentation and EMRs have additional - advantages and disadvantages for institutions

Computerized Documentation and EMRs

• Computerized documentation and EMRs have additional advantages and disadvantages for institutions such as:
• High purchase price but also saves money with end-of-shift charting
• Systems may may greatly between one institution and another making training more extensive for new employees

Protecting Health Information

• HIPAA legislation protects the rights of U.S. citizens to retain their health insurance when changing employment
• The original HIPAA legislation was expanded in 2022 to enact further measures to protect the privacy of health records and the security of that data

Privacy Standards

• Healthcare agencies must submit a written notice to all clients identifying the uses and disclosures of their health information such as to third parties for use in treatment or for payment for services

Workplace application

• In order efforts to limit access to the identity if clients:
• Computer screens must be oriented away from public view -Conversations regarding clients must take place in private faces where they cannot he overhead Documentation must be kent of those who have accessed a document

Documenting information requirements

• Each agency sets its own documentation policies, to be consistent
• In addition to identifying the, those policies generally indicate the type of information recorded on each chart form
• Each agency and facilities policies must be adhered to, violating the documentation policy could reduce legal protection if the record is subpoenaed

Abbreviating for Documentation

_A nurse should consult a list of permitted abbreviations (or "do not use list" to ensure there is no miscommunication or confusion to outside readers.

• Always prioritize accuracy over completeness when documenting by writing more with higher clarity and precision can aid over writing less and risking important facts being misrepresented or ommitted

Communication for Continuity and Collaboration through Documentations

Nurses use other methods of communication to promote continuity of care and collaboration among the health care providers involved.