Chapter_026-2.pptx

Fundamentals of Nursing, 11th Edition Patricia A. Potter, RN, MSN, PhD, FAAN Anne Griffin Perry, RN, MSN, EdD, FAAN Patricia A. Stockert, RN, BSN, MS, PhD Amy Hall, RN, BSN, MS, PhD, CNE  Chapter 26 Informatics and Documentation  Introduction  Documen...

Fundamentals of Nursing, 11th Edition Patricia A. Potter, RN, MSN, PhD, FAAN Anne Griffin Perry, RN, MSN, EdD, FAAN Patricia A. Stockert, RN, BSN, MS, PhD Amy Hall, RN, BSN, MS, PhD, CNE  Chapter 26 Informatics and Documentation  Introduction  Documentation  Key communication strategy  Produces a written account of patient data, clinical intervention and patient responses  Available to all members of the healthcare team  Allows others to track a patient’s clinical course 3  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 needed for quality and performance improvement  Serves as a resources for education and research 4  Interprofessional Communication Within the Medical Record (1 of 3)  Legal documentation  Reimbursement  Diagnosis-related groups  Auditing and monitoring  Education  Research 5  Interprofessional Communication Within the Medical Record (2 of 3)  Shift to electronic documentation  Electronic health record system (EHRS) American Recovery and Reinvestment Act (ARRA)  Health Information Technology for Economic and Clinical Health Act (HITECH)  Electronic health record (EHR) An individual’s lifetime computerized record  Electronic medical record (EMR) The record for an individual health care visit 6  Interprofessional Communication Within the Medical Record (3 of 3)  Maintaining privacy, confidentiality, and security of the health care record  Protected health information (PHI)  Privacy, confidentiality, and security mechanisms  Firewall  Password  Handling and disposing of information  Procedures for nursing students  Policies for the use of fax machines 7  Standards and Guidelines for Quality Nursing Documentation (1 of 2)  Guidelines for quality documentation  Factual  Accurate  Appropriate use of abbreviations  Current  Organized  Complete 8 Standards and Guidelines for Quality Nursing Documentation (2 of 2) 9  Methods of Documentation  Documentation of patient assessment data  Flow sheets  Progress notes  Charting by exception 10 Common Record-Keeping Forms within the Electronic Health Record  Admission nursing history form  Patient care summary  Care plans  Discharge summary forms 11  Documenting Communication with Providers and Unique Events  Telephone calls  Telephone and verbal orders  Incidence or occurrence reports 12  Acuity Rating Systems  Acuity rating system  Used to determine hours of care and number of staff required for a group of patients every shift or every 24 hours.  Patient’s acuity level  Based on the type and number of nursing interventions required by that patient over a 24-hour period 13  Documentation in the Long-Term Health Care Setting  Governed by  Individual state regulations  The Joint Commission (TJC)  Centers for Medicare and Medicaid Services (CMS) 14  Documentation in the Home Health Care Setting  Medicare has specific guidelines to establish eligibility for home care reimbursement.  Documentation is the quality control and the justification for reimbursement from Medicare, Medicaid, or private insurance companies.  Nurses use two different data sets to document clinical assessments and care provided in the home care setting.  OASIS  Omaha system 15  Case Management and Use of Critical Pathways  Case management model  Incorporates an interprofessional approach to delivery and documentation of patient care  Critical pathways  Interprofessional care plans that 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 16  Informatics and Information Management in Health Care (1 of 3)  Health care information technology (HIT)  Used to enhance quality and efficiency of care  Health care information system (HIS)  Two types: a clinical information system and an administrative information system  Clinical information system (CIS)  Example: computerized provider order entry (CPOE) 17  Informatics and Information Management in Health Care (2 of 3)  Nursing clinical information systems (NCIS)  Two designs: nursing model and critical pathway  Advantages: better information access, better documentation quality, reduced errors of omission, reduced hospital costs, increased nurse job satisfaction, clinical database development  Clinical decision support systems (CDSS)  Aids and supports clinical decision making 18  Informatics and Information Management in Health Care (3 of 3)  Nursing informatics  Specialty area of practice  Integrates nursing science, computer science, and information science  Informatics competencies for nursing graduates 19