CH 26- Informatics and Documentation

Documentation in Nursing Practice

• Documentation is a vital aspect of nursing practice, producing a written account of patient data, clinical decisions, and interventions in a health record.
• It is a key communication strategy that facilitates continuity of care, tracks patient outcomes, and provides accountability for care provided.

Importance of Documentation

• Documentation is essential for:
  • Quality of care: provides a detailed account of the level of care delivered.
  • Standards of regulatory agencies and nursing practice: ensures compliance with regulations and standards.
  • Reimbursement: supports financial billing and reimbursement for care provided.
  • Legal guidelines: provides a legal record of care, justifying financial billing and reimbursement.
  • Interprofessional communication: facilitates communication among health care providers.
  • Education and research: serves as a resource for nursing and health care education and research.

Health Care Record

• The health care record is a:
  • Valuable source of data for health care providers.
  • Resource for education and research.
  • Permanent, legal documentation of patient information.
  • Confidential and accurate account of patient health care status.
• It is available to all members of the health care team, allowing for:
  • Safe and effective clinical decision-making.
  • Identification of patterns and trends in patient care.
  • Development of clinical knowledge.

Electronic Health Record (EHR)

• An EHR is an individual's lifetime computerized record, integrating all patient information into one record.
• It includes:
  • Results of diagnostic studies, including images.
  • Decision support software programs.
  • Ability to store unlimited patient records.
• EHR benefits for nursing include:
  • Comparing current clinical data with previous health care encounters.
  • Maintaining ongoing symptom management.
  • Providing an ongoing record of health education.

Confidentiality and Security

• Nurses must protect patient confidentiality and adhere to HIPAA guidelines.
• Ensuring appropriate access to and confidentiality of personal health information is the responsibility of all health care professionals.
• Security measures include:
  • Firewalls.
  • Antivirus and spyware-detection software.
  • Strong passwords and frequent changes.
  • Physical and logical restrictions to protect information.
• Printed information from the record must be safeguarded and destroyed when no longer needed.

Electronic Health Record (EHR)

• Nurses use flow sheets to document patient physiological data and routine care, organized by body system
• Flow sheets provide current patient information accessible to all health care team members
• They facilitate quick identification of patient trends over time

Charting by Exception (CBE)

• Philosophy: all standards for normal assessment findings or routine care activities are met unless otherwise documented
• Well-designed flow sheets are a key part of a good exception-based documentation system within the EHR

Nursing Assessment and Care Plans

• Nursing history forms are used to identify relevant nursing diagnoses or problems at admission
• Computerized documentation systems generate a patient care summary document for each patient at the beginning and/or end of each shift
• Standardized care plans are useful for QI audits and improve continuity of care among professional nurses

Discharge Planning

• Interprofessional discharge planning begins at admission and involves identifying key clinical outcomes and timelines
• Discharge documentation includes medications, diet, community resources, follow-up care, and contact information
• The discharge summary document is printed out and given to the patient on discharge

Telephone Orders (TOs) and Verbal Orders (VOs)

• TOs and VOs should be used only when absolutely necessary
• A nurse receiving a TO or VO enters the complete order into the computer using CPOE software or writes it out on a physician’s order sheet
• The receiver of a VO or TO records it and reads it back to the prescriber to ensure accuracy

Incident Reports

• Incident reports contain confidential information and are limited to individuals responsible for reviewing the forms
• An objective description of the incident, observed events, and follow-up actions are documented in the patient’s health care record
• The patient’s response to the incident is also evaluated and documented

Acuity Rating Systems

• Acuity rating systems determine the hours of care and number of staff required for a given group of patients
• A patient’s acuity level is based on the type and number of nursing interventions required over a 24-hour period
• Acuity levels range from 1 (independent in all but one or two aspects of care) to 5 (totally dependent in all aspects of care)

Health Information Technology (HIT)

• HIT includes computer hardware and software dedicated to the collection, storage, processing, retrieval, and communication of patient care information
• A health care information system (HIS) consists of clinical and administrative information systems
• HIT enhances the quality and efficiency of care provided

Clinical Information Systems (CIS)

• A CIS is a large, computerized database management system that accesses patient data needed to plan, implement, and evaluate care
• CIS includes monitoring systems, order entry systems, laboratory, radiology, and pharmacy systems
• Computerized provider order entry (CPOE) system allows health care providers to directly enter standardized orders for patient care into a medical record

Nursing Clinical Information Systems (NCIS)

• NCIS incorporates nursing informatics principles to support nursing process activities and manage care delivery
• Two NCIS designs: nursing process design and protocol or critical pathway design
• NCIS offers advantages such as better access to information, enhanced quality of documentation, and increased nurse job satisfaction

Home Health Care Documentation

• Medicare has specific guidelines to establish eligibility for home care reimbursement
• Documentation serves as quality control and justification for reimbursement from Medicare, Medicaid, or private insurance companies
• Nurses use two primary data sets for documentation in home care settings:
  • OASIS (Outcome and Assessment Information Set)
  • Omaha system