Patient Records and Documentation Ethics

Documentation

• Five basic purposes of patient records include documented communication, permanent record for accountability, legal record of care, teaching, and research and data collection.
• Audits, diagnosis-related groups (DRGs), and nurses' notes are also purposes of patient records.
• Electronic Health Records (EHRs) and Personal Health Records (PHRs) are used.
• EHR and PHR features include: use of the record, ease of use and documentation, point-of-care, computers on wheels (COWS), and security.
• Situation, Background, Assessment, and Recommendation (SBAR) method is beneficial for communication between providers and nurses.
• Joint Commission recognizes SBAR meets National Patient Safety Goals.
• Quality and accuracy of nurses' notes are important.
• Correct spelling, grammar, punctuation, penmanship, and writing skills are essential.
• Information in the chart should be clear, concise, complete, and accurate.
• The registered nurse (RN) is responsible for initial admission nursing history, physical assessment, and developing a care plan.

Recording Methods

• Traditional charts
• Narrative
• Problem-oriented medical records (POMR)
• Focus charting
• Charting by exception
• Alternative forms (e.g., Kardex/Rand, nursing care plans)

Other Documentation Forms

• Incident reports
• 24-hour patient care reports and acuity forms
• Acuity charting
• Discharge summaries

Documentation and Clinical (Critical) Pathways

• Clinical pathways coordinate medical and nursing interventions.
• All disciplines develop integrated care plans for projected length of stay.
• Clinical pathways monitor patient progress and serve as a documentation tool.

Home Health Care Documentation

• Documentation provides quality control and reimbursement from insurance companies.
• Patient education and demonstration of learning are noted.
• Coordination of services and compliance with regulations are reflected by all health care team members.

Long-Term Health Care Documentation

• Omnibus Budget Reconciliation Act (OBRA) of 1987 regulates standards for resident assessment, individualized care plans, and practitioner qualifications.
• Each state's Department of Health (DOH) regulates the frequency of written nursing records of residents.
• A multidisciplinary approach supports assessment and planning processes for patient care.

Special Issues in Documentation

• Record ownership and access
• Confidentiality
• Electronic documentation
• Use of fax machines