Nursing Documentation and Medical Records

Importance of Documentation

• 25% of a nurse's time is spent on documentation, which needs to be accurate and comprehensive.
• Effective documentation positively affects patient health outcomes and minimizes error risks.

Purpose of Medical Record

• Medical records are vital sources of data for healthcare teams, facilitating communication, care planning, and legal records of care provided.
• Records include biographical information, medical history, patient perceptions, and risk factors.

Communication and Care Planning

• Clear documentation is essential for effective communication among healthcare teams.
• Nursing history and physical assessment provide baseline data about a patient's health status upon admission.

Legal Documentation

• Accurate documentation is crucial for legal defense against claims associated with nursing care.
• Incomplete or inaccurate documentation can lead to liability.
• Nurses must document individualized, goal-directed care, patient responses, and monitoring.

Common Documentation Mistakes

• 7 common mistakes include:
  • Failing to record patient health or drug info
  • Failing to record nursing actions
  • Failing to report medications given
  • Recording on the wrong chart
  • Failing to document medication discontinuation
  • Failing to record drug reactions or changes to patient condition
  • Transcribing orders improperly

Legal Guidelines for Documentation

• Enter objective, factual descriptions of patient behavior or healthcare provider actions.
• Avoid rushing to complete documentation and ensure entries are thorough and factual.
• Document as soon as possible after an event to ensure accuracy.
• Do not record errors made by others; instead, clarify orders and outcomes.
• Do not prechart or leave computer screens unattended.

Guidelines for Written Documentation

• Correct errors by drawing a single line through the mistake, writing "error," and signing with date and credentials.
• Chart consecutively, line by line, and sign at the end.
• Record entries legibly in black ink, avoiding felt-tip pens or erasable ink.

Funding and Resource Management

• Patient records help determine allocation of financial resources.

Auditing and Monitoring

• Regular review of patient records helps evaluate quality and appropriateness of care.

Research

• Patient records provide statistical data for research and quality improvement programs.
• Examples include investigating infection incidents in patients with specific intravenous catheters.

Education

• Patient records provide valuable learning resources for nursing education.
• Records contain information on diagnoses, signs, symptoms, and therapies, helping students identify patterns and anticipate care requirements.

Importance of Documentation

• 25% of a nurse's time is spent on documentation, which needs to be accurate and comprehensive.
• Effective documentation positively affects patient health outcomes and minimizes error risks.

Purpose of Medical Record

• Medical records are vital sources of data for healthcare teams, facilitating communication, care planning, and legal records of care provided.
• Records include biographical information, medical history, patient perceptions, and risk factors.

Communication and Care Planning

• Clear documentation is essential for effective communication among healthcare teams.
• Nursing history and physical assessment provide baseline data about a patient's health status upon admission.

Legal Documentation

• Accurate documentation is crucial for legal defense against claims associated with nursing care.
• Incomplete or inaccurate documentation can lead to liability.
• Nurses must document individualized, goal-directed care, patient responses, and monitoring.

Common Documentation Mistakes

• 7 common mistakes include:
  • Failing to record patient health or drug info
  • Failing to record nursing actions
  • Failing to report medications given
  • Recording on the wrong chart
  • Failing to document medication discontinuation
  • Failing to record drug reactions or changes to patient condition
  • Transcribing orders improperly

Legal Guidelines for Documentation

• Enter objective, factual descriptions of patient behavior or healthcare provider actions.
• Avoid rushing to complete documentation and ensure entries are thorough and factual.
• Document as soon as possible after an event to ensure accuracy.
• Do not record errors made by others; instead, clarify orders and outcomes.
• Do not prechart or leave computer screens unattended.

Guidelines for Written Documentation

• Correct errors by drawing a single line through the mistake, writing "error," and signing with date and credentials.
• Chart consecutively, line by line, and sign at the end.
• Record entries legibly in black ink, avoiding felt-tip pens or erasable ink.

Funding and Resource Management

• Patient records help determine allocation of financial resources.

Auditing and Monitoring

• Regular review of patient records helps evaluate quality and appropriateness of care.

Research

• Patient records provide statistical data for research and quality improvement programs.
• Examples include investigating infection incidents in patients with specific intravenous catheters.

Education

• Patient records provide valuable learning resources for nursing education.
• Records contain information on diagnoses, signs, symptoms, and therapies, helping students identify patterns and anticipate care requirements.

Purpose of Medical Record

• A vital source of data for all members of the healthcare team, facilitating communication, care planning, and legal record of care provided.
• A source for research data and learning resources for nursing education.

Communication and Care Planning

• The medical record must be clear for all readers, including the nurse's communication with the patient.
• Admitting nursing history and physical assessment are comprehensive and provide baseline data about the patient's health status upon admission.
• Includes biographical information, method of admission, reason for admission, code status, allergies, current medications, brief medical-surgical history, patient's perception about illness, and risk factors.
• The medical record provides data for nurses to identify and support nursing diagnosis, establish expected outcomes of care, and plan and evaluate interventions.

Legal Documentation

• Accurate documentation is the best defense against legal claims associated with nursing care.
• The medical record is vital evidence in negligent practice lawsuits and is often considered the most reliable evidence during legal proceedings.
• 7 common documentation mistakes:
  • Failing to record patient health or drug information
  • Failing to record nursing actions
  • Failing to report medications given
  • Recording on the wrong chart
  • Failing to record discontinuation of medication
  • Failing to record a drug reaction or changes to patient condition
  • Transcribing orders improperly
• Legal guidelines for documentation:
  • Enter only objective and factual descriptions of a patient's behavior or the actions of another healthcare provider.
  • Quote all patient statements.
  • Avoid rushing to complete documentation.
  • Document as soon after the event as possible to ensure accuracy.

Funding and Resource Management

• Patient records help determine where to use financial resources.
• Auditing and monitoring involve reviewing patient records to evaluate the quality and appropriateness of care.

Research

• Statistical data can be gathered from patient records.
• Examples of research include quality improvement programs, such as investigating incidents of infections in patients with a specific type of intravenous catheter.

Education

• Patient records provide information on diagnoses, signs, symptoms of disease, successful and unsuccessful therapies, diagnostic findings, and patient behaviors.
• No two patients have identical records, but during clinical training, healthcare students can review records of patients with similar health problems to identify patterns of information and anticipate the type of care required.

Shift to Electronic Documentation

• Electronic health records (EHRs) and electronic medical records (EMRs) are used interchangeably, but there is a difference between them.
• EHR is the digital version of patient data, while EMR is the legal record that describes a single encounter or visit by a patient to a hospital or outpatient healthcare setting.
• General benefits of an EHR:
  • Improvement in the readability, organization, and accuracy of documentation
  • Increased ability to make timely clinical decisions with easier access to data
  • Improvement in quality of care provided
  • Increased satisfaction among caregivers
  • Positive impact on patient safety through reduction of errors

Confidentiality

• Nurses are legally and ethically obligated to keep patient information confidential.
• Only authorized members of the healthcare team have access to the medical record and may discuss treatment, assessment, etc.
• Patients have the right to request copies of their medical records and read information contained.
• Patients must give written consent for the release of medical information.
• Access to EHR is traceable through user login.
• Nursing students must ensure that written or electronic material used in student clinical practice do not include patient identifiers and are disposed of properly.
• Privacy, confidentiality, and security mechanisms:
  • Canada has provincial/territorial and national privacy legislation to protect personal health information in electronic and other forms.
  • Under PIPEDA, ensuring appropriate access to and confidentiality of health information is the responsibility of everyone working in healthcare.
  • PHI includes individually identifiable health information.
  • PIPEDA is federal legislation that protects personal information, including health information.
  • Most security mechanisms for computerized information systems use a combination of logical and physical restrictions to protect information.
  • Other security measures include firewalls, antivirus, and encryption.
• Handling and disposing of information:
  • The nurse cannot leave it out where it may be viewed by unauthorized people.
  • Destroy/shred anything that is printed when information is no longer needed.
  • If health information needs to be sent electronically, it must be encrypted.

Purpose of Medical Record

• A vital source of data for all members of the healthcare team, facilitating communication, care planning, and legal record of care provided.
• A source for research data and learning resources for nursing education.

Communication and Care Planning

• The medical record must be clear for all readers, including the nurse's communication with the patient.
• Admitting nursing history and physical assessment are comprehensive and provide baseline data about the patient's health status upon admission.
• Includes biographical information, method of admission, reason for admission, code status, allergies, current medications, brief medical-surgical history, patient's perception about illness, and risk factors.
• The medical record provides data for nurses to identify and support nursing diagnosis, establish expected outcomes of care, and plan and evaluate interventions.

Legal Documentation

• Accurate documentation is the best defense against legal claims associated with nursing care.
• The medical record is vital evidence in negligent practice lawsuits and is often considered the most reliable evidence during legal proceedings.
• 7 common documentation mistakes:
  • Failing to record patient health or drug information
  • Failing to record nursing actions
  • Failing to report medications given
  • Recording on the wrong chart
  • Failing to record discontinuation of medication
  • Failing to record a drug reaction or changes to patient condition
  • Transcribing orders improperly
• Legal guidelines for documentation:
  • Enter only objective and factual descriptions of a patient's behavior or the actions of another healthcare provider.
  • Quote all patient statements.
  • Avoid rushing to complete documentation.
  • Document as soon after the event as possible to ensure accuracy.

Funding and Resource Management

• Patient records help determine where to use financial resources.
• Auditing and monitoring involve reviewing patient records to evaluate the quality and appropriateness of care.

Research

• Statistical data can be gathered from patient records.
• Examples of research include quality improvement programs, such as investigating incidents of infections in patients with a specific type of intravenous catheter.

Education

• Patient records provide information on diagnoses, signs, symptoms of disease, successful and unsuccessful therapies, diagnostic findings, and patient behaviors.
• No two patients have identical records, but during clinical training, healthcare students can review records of patients with similar health problems to identify patterns of information and anticipate the type of care required.

Shift to Electronic Documentation

• Electronic health records (EHRs) and electronic medical records (EMRs) are used interchangeably, but there is a difference between them.
• EHR is the digital version of patient data, while EMR is the legal record that describes a single encounter or visit by a patient to a hospital or outpatient healthcare setting.
• General benefits of an EHR:
  • Improvement in the readability, organization, and accuracy of documentation
  • Increased ability to make timely clinical decisions with easier access to data
  • Improvement in quality of care provided
  • Increased satisfaction among caregivers
  • Positive impact on patient safety through reduction of errors

Confidentiality

• Nurses are legally and ethically obligated to keep patient information confidential.
• Only authorized members of the healthcare team have access to the medical record and may discuss treatment, assessment, etc.
• Patients have the right to request copies of their medical records and read information contained.
• Patients must give written consent for the release of medical information.
• Access to EHR is traceable through user login.
• Nursing students must ensure that written or electronic material used in student clinical practice do not include patient identifiers and are disposed of properly.
• Privacy, confidentiality, and security mechanisms:
  • Canada has provincial/territorial and national privacy legislation to protect personal health information in electronic and other forms.
  • Under PIPEDA, ensuring appropriate access to and confidentiality of health information is the responsibility of everyone working in healthcare.
  • PHI includes individually identifiable health information.
  • PIPEDA is federal legislation that protects personal information, including health information.
  • Most security mechanisms for computerized information systems use a combination of logical and physical restrictions to protect information.
  • Other security measures include firewalls, antivirus, and encryption.
• Handling and disposing of information:
  • The nurse cannot leave it out where it may be viewed by unauthorized people.
  • Destroy/shred anything that is printed when information is no longer needed.
  • If health information needs to be sent electronically, it must be encrypted.