Medical Records: Purpose, HIPAA, and Charting

Medical Records

• Medical records contain information about a person.
• Health records and client records are alternate names.
• It is false medical records cannot be shared among health care providers.

Uses of Medical Records

• Medical records provide a permanent account.
• Medical records facilitate sharing of information.
• Medical records are used for quality assurance
• Medical records are used for accreditation
• Medical records are used for reimbursement
• Medical records are used for education and research
• Medical records are used for legal evident purposes

The Joint Commission (TJC)

• The Joint Commission (TJC) establishes criteria to reflect high standards for client safety and institutional health care.
• Representatives of the TJC periodically inspect health care agencies to assess the quality of care.
• Agencies are accredited based on inspections.

Client Access to Records

• HIPAA legislation exists.
• Clients can see their medical and billing records.
• Clients can request changes to inaccurate information.
• Clients can be informed about who has seen their medical records.

Source-Oriented Records

• These records are organized by documented information source.
• Source-oriented records contain separate forms for each role: physicians, nurses, dietitians, and rehabilitation therapists.
• Source-oriented records can provide fragmented documentation.

Problem-Oriented Records

• These records are organized according to the client's health problems.
• Problem-oriented records have four major components: database, problem list, plan of care, and progress notes.
• Information emphasizes goal-directed care; promotes recording of pertinent information and facilitates communication among health care providers.

Methods of Charting

• Narrative charting (pg. 117)
• SOAP/ Focus charting
• DAR charting
• Charting by exception
• Electronic charting

SOAP/ Focus charting

• Patient Darlene is being seen for follow-up of hypertension (HTN).
• Darlene takes 25mg HCTZ daily and does not take OTC medications.
• Darlene's vitals are: 153/80, pulse 76, respirations 16, pulse oximetry 98%, and temperature 98.0F.
• Darlene lost 53 pounds in the past 3 months on a low-fat diet and walking 10 minutes per day.
• Darlene weighs 155 pounds today.
• No edema noted on Darlene's lower extremities.
• Darlene drinks two glasses of wine each evening.

DAR Notes Scenario 1

• Patient temperature is 101.8F at 7:30 am.
• The patient's skin is hot, and they are visibly sweating.
• Implementing interventions of a cool compress and encouraging fluids.
• At 8:15 am, the patient's temperature is rechecked and found to be 99.5F.

DAR Notes Scenario 2

• Post procedure at 1015 with patient reports feeling ill and vomits at 0950

Protecting Health Information

• HIPAA protects the rights of U.S. citizens to retain their health insurance.
• Health care agencies must safeguard written, spoken, and electronic health information.
• Health care agencies must obtain authorization from clients to release information.
• Submit written notice to all clients identifying uses and disclosures of health information.
• Obtain client's signature indicating the knowledge of disclosure of information and the right to know who has seen the records.
• Limit casual access to identity of client and health information.
• Health agencies must ensure protection of electronic data

Workplace Applications

• Client names are not visible to the public on charts.
• Clipboards must obscure private client data, including name
• Whiteboards cannot link client name with diagnosis, procedure, or treatment
• Computer screens are not visible to the public; flat screen monitors are recommended
• Conversations regarding clients occur in private.
• Fax machines, filing cabinets, and records are inaccessible to the public.
• Implement a cover sheet on all faxes or emails warning about confidential information.
• Light boxes (for X-ray, scan results) located in private areas.
• Documentation kept on all who have accessed a client's records.

Documenting Information

• Documentation policies indicate:
• The type of information recorded
• The people responsible for charting
• The frequency for making entries on the record

Abbreviations

• Abbreviations shorten documentation time.
• Agencies provide lists of approved abbreviations with meanings.
• Only use abbreviations on the agency's approved list.
• TJC's "Do Not Use" list assists in avoiding and reducing medical errors.

Documentation Time

• Traditional time: Two 12-hour revolutions are identified with hour and minute, followed by AM or PM.
• Military time is based on a 24-hour clock. A different four-digit number is used for each hour and minute of the day.
• The first two digits indicate the hour within the 24-hour period.
• The last two digits indicate the minutes.

Nursing Benefits of Electric Documentation

• Information is always legible.
• The date/time of the documentation is automatically recorded.
• Abbreviations and terms are consistent with agency-approved lists.
• Omissions are fewer.
• Simultaneously from different workstations, multiple health care providers use the medical record.
• Documentation formats prompt for data required by The Joint Commission (TJC) e.g., pain and fall assessments.
• Entries are automatically credited to the user.
• Reduces medication errors.
• Quickly obtains test results.
• Frees nurses from transcribing physicians' orders and making phone calls for clarification.
• Firewalls and passwords prevent breaches in confidentiality.
• Is backed up on systems outside the agency of origin and is therefore protected from destruction should there be a fire or other type of disaster.

Disadvantages of Electronic Medical Records

• Systems are expensive
• Extensive training
• Requires IT support staff.
• Passwords must be changed regularly.
• Downtime, upgrades, and power failures can delay documentation and access to the full record.
• Paper charting is required when the system is down.
• Fewer narrative entries due to structured options.
• Information is scattered among various files.

Charting Guidelines

• Charting should not be time-consuming to write and read.
• Everyone involved in the care of a client makes entries in the same location.
• The nurse addresses specific content in charted progress notes.
• Assessments documented on a separate form give the client's problems a corresponding number for quick access.
• Abnormal assessment findings should also be documented separately.
• Information should always be legible.
• Abbreviations and terms should be consistent with agency approved lists.
• The documentation date and time should be recorded.

Written Forms of Communication

• Nursing care plan: contains the client's problems, goals, and nursing orders.
• Nursing Kardex: quick reference for current information about the client.
• Checklists: documentation of routine care with a check mark or initials.
• Flow sheets: documentation with sections for recording frequently repeated assessment data.

Interpersonal Communication

• Change-of shift-reports
• Team conferences
• Client rounds
• Telephone
• SBAR (Situation, Background, Assessments, Recommendation)

Explore the function of medical records, covering HIPAA regulations, client rights, and charting methods like SOAP. Learn about record organization, error correction, and the role of goal-directed healthcare. Understand the standards set by The Joint Commission (TJC).