Nursing Informatics and Documentation (Chapter 26)

Documentation and Informatics

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 (diagnosis-related groups)
• Auditing and monitoring
• Education
• Research
• Shift to electronic documentation (electronic health record system (EHRS) and electronic health record (EHR))

Maintaining Privacy, Confidentiality, and Security

• Protected health information (PHI)
• Mechanisms: firewall, password, and procedures for handling and disposing of information
• Policies for the use of fax machines

Standards and Guidelines for Quality Nursing Documentation

• Factual
• Accurate
• Appropriate use of abbreviations
• Current
• Organized
• Complete

Methods of Documentation

• Documentation of patient assessment data: 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
• Based on the type and number of nursing interventions required by a patient over a 24-hour period

Documentation in Long-Term and Home Health Care Settings

• Governed by individual state regulations, The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS)
• Medicare has specific guidelines to establish eligibility for home care reimbursement
• Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance companies
• OASIS and Omaha system data sets are used to document clinical assessments and care provided in the home care setting

Case Management and Use of Critical Pathways

• Case management model incorporates an interprofessional approach to delivery and documentation of patient care
• Critical pathways identify patient problems, key interventions, and expected outcomes within an established time frame
• Variances: unexpected outcomes, unmet goals, and interventions not specified within a critical pathway

Informatics and Information Management in Health Care

• Health care information technology (HIT) enhances quality and efficiency of care
• Health care information system (HIS) includes clinical information system (CIS) and administrative information system
• Clinical information system (CIS) example: computerized provider order entry (CPOE)
• Nursing clinical information systems (NCIS) have two designs: nursing model and critical pathway
• Clinical decision support systems (CDSS) aid and support clinical decision making
• Nursing informatics is a specialty area of practice that integrates nursing science, computer science, and information science

Documentation and Informatics

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 (diagnosis-related groups)
• Auditing and monitoring
• Education
• Research
• Shift to electronic documentation (electronic health record system (EHRS) and electronic health record (EHR))

Maintaining Privacy, Confidentiality, and Security

• Protected health information (PHI)
• Mechanisms: firewall, password, and procedures for handling and disposing of information
• Policies for the use of fax machines

Standards and Guidelines for Quality Nursing Documentation

• Factual
• Accurate
• Appropriate use of abbreviations
• Current
• Organized
• Complete

Methods of Documentation

• Documentation of patient assessment data: 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
• Based on the type and number of nursing interventions required by a patient over a 24-hour period

Documentation in Long-Term and Home Health Care Settings

• Governed by individual state regulations, The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS)
• Medicare has specific guidelines to establish eligibility for home care reimbursement
• Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance companies
• OASIS and Omaha system data sets are used to document clinical assessments and care provided in the home care setting

Case Management and Use of Critical Pathways

• Case management model incorporates an interprofessional approach to delivery and documentation of patient care
• Critical pathways identify patient problems, key interventions, and expected outcomes within an established time frame
• Variances: unexpected outcomes, unmet goals, and interventions not specified within a critical pathway

Informatics and Information Management in Health Care

• Health care information technology (HIT) enhances quality and efficiency of care
• Health care information system (HIS) includes clinical information system (CIS) and administrative information system
• Clinical information system (CIS) example: computerized provider order entry (CPOE)
• Nursing clinical information systems (NCIS) have two designs: nursing model and critical pathway
• Clinical decision support systems (CDSS) aid and support clinical decision making
• Nursing informatics is a specialty area of practice that integrates nursing science, computer science, and information science

This quiz covers the fundamentals of informatics and documentation in nursing, including documentation as a key communication strategy and its importance in healthcare.