Documentation and EHR - PDF

DOCUMENTATION & ELECTRONIC INFORMATION COURSE OUTCOME Describe effective communication with patients and interprofessional collaborative practice members. Discuss the use of information and technology to effectively support decision-making and reduce risk potential. Explain the profess...

DOCUMENTATION & ELECTRONIC INFORMATION COURSE OUTCOME Describe effective communication with patients and interprofessional collaborative practice members. Discuss the use of information and technology to effectively support decision-making and reduce risk potential. Explain the professional, ethical and legal guidelines used in nursing practice. COMPETENCY Discuss the roles of the inter-professional collaborative practice members. Discuss the laws and guidelines for patient confidentiality and organizational integrity. Identify ethical and legal guidelines for nursing practice. CONCEPT Collaboration: Process in which the interprofessional healthcare team works toward a common goal by combining their skills, knowledge, and resources to improve client outcomes while avoiding duplication of effort. CONCEPTS Communication: The process of human interaction: verbal and nonverbal, written and unwritten, planned and unplanned. Interactions between individuals, groups or communities that convey thoughts, ideas, feelings, and information. It is a basic component of human relationships. CONCEPT Legal Issues: Encompasses the rights, responsibilities, and scope of nursing practice as defined by state nurse practice acts and as legislated through criminal and civil law. All clients have a privilege, demand or claim by virtue of law or right (that which is proper or just) to expect competent nursing services. CONCEPT Informatics: A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice (ANA, 2008, p.1) UNIT OUTCOMES Discuss documentation as a method of communicating within the interprofessional collaborative practice members. Describe guidelines for documentation that enhance safe individualized care. Explore selected common documentation formats. UNIT OUTCOMES CONTINUED Identify ways to implement Health Insurance Portability and Accountability Act (HIPAA) with electronic and written documentation. Describe the legal and ethical considerations of documentation. Describe the Nursing Information System (Electronic Health Record) used for documenting patient information. Identify the components of clinical decision support systems used to reduce risk potentials. CONFIDENTIALITY Patient’s have a right to privacy and confidentiality Spoken and written word Confidentiality refers to the assurance that the patient has a right to have their information kept private and will not be disclosed without their consent. CONFIDENTIALITY Nurses are legally and ethically obligated to keep all patient information confidential. Nurses are responsible for protecting records from all unauthorized readers. Keep your computer password secure. HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary. STUDENT AND STAFF ROLE Be cognizant how one collects and transports patient data. Not have any patient identifiers on their paperwork, including birth date, social security number, room number, name, name of the facility or medical record number. Be very careful of requisitions, specimen labels STUDENT AND STAFF ROLE Access only patients’ medical records for information needed to provide safe and effective patient care. All record access is tracked. Your documentation is part of a legal record. You are responsible for your documentation. HOW DO YOU MAINTAIN CONFIDENTIALITY OF THE INFORMATION YOU USE AT THE CLINICAL SITE? DOCUMENTATION STANDARDS Current documentation standards require that each patient have an assessment before care is provided and continuously throughout their stay including; Physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs Joint Commission standards require that documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning. DOCUMENTATION: FACILITATES INTER- PROFESSIONAL COMMUNICATION FORMS OF DOCUMENTATION: Records or chart (Paper or Electronic) Confidential permanent legal document Reports Oral or written (Radiology Technician, MLT, Nurse to Nurse) Conferences (Prescriber, Clinical Pharmacist) Team members communicating in a group Referrals (OT, PT, Social Worker) Arrangement for services by another care provider  PURPOSE OF A PATIENT RECORD Communication Legal Documentation Reimbursement Education Research Auditing  PURPOSES OF A PATIENT RECORD Communication – between Legal documentation – and among “Care not documented is Communication interprofessional members Legal care not provided.” Reimbursement –based on documentation Education – Students are documented patient care expected to review patient Reimbursement Education records to provide safe quality care. Research Research – statistical data Auditing/ Auditing/monitoring-to from patients’ records formally review monitoring used to change policies documented patient care and procedures to improve quality of care. LEGAL GUIDELINES FOR DOCUMENTATION  All medical records are subject to review Center for Medicare/Medicaid LEGAL CONSIDERATION The Joint Commission S Court of law Risk management Patient  Not documented…..not done Poor documentation….poorly LEGAL done PERSPECTI VE Incorrectly documented….potentially fraudulent  Facts GOOD Observed behaviors DOCUMENTATION Services rendered Response to services rendered  Specific Clear GOOD Complete DOCUMENTATION Concise Timely Sequential PATIENT RIGHTS TO MEDICAL RECORD Patients do have a right to their medical record Must go through a formal process for official copy EHR increased access Progress Notes Nurses Notes Health care results LEGAL GUIDELINES FOR DOCUMENTATION Paper: Write legibly, black ink Write words out. Do not use abbreviations unless approved by the organization NEVER chart in advance NEVER chart under someone else’s documentation NEVER change someone’s documentation LEGAL GUIDELINES FOR DOCUMENTATION Document facts Document subjective and objective information Do not enter personal opinions Ex. Patient was rude Document in a timely way Ongoing vs end of shift LEGAL GUIDELINES FOR DOCUMENTATION Sign document as What do you do if directed from the you make an error in facility. a written document? Typically: first initial, last name, title (Student Nurse) LEGAL GUIDELINES FOR DOCUMENTATION Begin each note entry with the date/time using a 24 hour clock and end with your signature and title A nurse’s signature on an entry in a record designates accountability for the contents of that entry First - Last - Legal Status: Pat Lake SNLCC ________________________________________ DOCUMENTATION GUIDELINES DOCUMENTATION PRINCIPLES MILITARY TIME Accuracy Sequence Appropriateness Completeness Conciseness Legal prudence LEGAL GUIDELINES FOR RECORDING Do not leave blank spaces or lines in nurses’ notes. Correct Format Sample 01-01-29 0800 Dr. Box called regarding current IV order for 1,000 ml 0.9% Sodium Chloride infusing at 100 ml/hour. Current Sodium level elevated 190 mEq/L: Dr. Box changed order to 1,000 ml 5% Dextrose in water to infuse at 100ml/hour: Order documented by Dr. Box.; 1,000 mL 5% Dextrose and Water hung at 0810 infusing at 100 ml/hr. Jane Doe RN LEGAL GUIDELINES FOR RECORDING Incorrect Format Sample 01-01-29 0800 Dr. Box called regarding IV order for 1,000 ml 0.9% SodClo Sodium level elevated 190 mEq/L. JDoeRN 01-01-29 0815 Dr. Box changed order 1,000 ml 5% Dextrose in Water: Order documented by Dr. Box electronically. Jane Doe RN LEGAL GUIDELINES FOR RECORDING Chart only for yourself, not for others. Pat Doe RN gave pain medication. May Wert SNLCC Avoid generalizations – Make your decision Seems/Appears/Perhaps No complaints or No reports Complaints – Patient’s do not complain - Report Normal - specify or will you remember in 5 years normal orientation versus alert and oriented x 3 LEGAL GUIDELINES FOR DOCUMENTATION “Noted” “Patient” LEGAL GUIDELINES FOR RECORDING Double check the name on the record is the record you want to be documenting in. Quote the patient or describe the patient’s behavior; “I am in pain.” “I want to go home.” Document all interventions: If an intervention is not documented, it is considered not done. Document response to interventions  What is the correct method for correcting an error or mistaken CORRECTIO entry in a paper record? N OF AN (Electronic will guide you ENTRY through the same process) CORRECTION OF AN ENTRY I write : IV right Draw a single line through the word(s), write the word "error” or “mistaken entry” above it, sign your initials, and date it. Then record correctly. mistaken entry MP 01-01-29 IV right left SAMPLE NARRATIVE NURSE’S NOTES REVIEW AND MAKE USE THE EXAMPLE REFLECT ADJUSTMENTS TO GUIDE BASED ON YOUR ORGANIZATION PATIENT SAMPLE NARRATIVE NURSE’S NOTES Review and Reflect: Clinical Narrative Example You are expected to be able to write a competent narrative for your patient this semester. RECOMMENDATIONS? Capped angio present in right hand- no redness, edema, drainage, pallor, or warmth noted. Patient voices no complaints of pain at IV site. RECOMMENDATIONS: Capped angio present in right hand- no redness, edema, drainage, pallor, or warmth noted. Patient denies pain at IV site. Capped angio present in right hand- no redness, edema, drainage, pallor, or warmth: denies pain at IV site. CASE STUDY Mrs. Smith is a 93- year-old patient with fractures in her lower spine resulting from severe osteoarthritis that can be treated with surgery. She reports her pain as 10 out of 10. CASE STUDY What would be your first action when you hear a patient report pain as 10 out of 10? What would you record in the chart for Mrs. Smith?  CASE STUDY Mrs. Smith tells you, “I'm dreading surgery. Last time, I had such pain when I got out of bed.” CASE STUDY What type of data is provided by Mrs. Smith’s statement? How would you record Mrs. Smith’s statement in your report? Mrs. Smith’s statement provides ______ data. Record her statement word-for-word, in quotation marks. Pt. stated, “I'm dreading surgery. Last time, I had such pain when I got out of bed.” Discussed post operative pain management plan – verified understanding using Teach-back “that’s a lot different than they use to do.” Jane Doe RN  Paper record Must have the chart to write in it METHODS Multiple interprofessional team members may want the OF Electronic same recordhealth record at the same time RECORDIN (EHR) A digital version of a patient’s G medical record Integrates all of a patient’s information in one record Improves continuity of care EHR Advantages of an electronic health record (EHR) for nursing include: Able to compare ongoing clinical data about a patient with prior information PATTERN or TRENDS Maintain an ongoing record of a patient’s health education. Uses standard documentation: All nurses document about the same topics on every patient to increase consistent documentation between and among nurses. METHODS OF RECORDING Narrative The method USED ON PAPER and EHR progress notes by all nurses. Organized by the time of occurrence. At 0830 ate 100% of breakfast but you were involved with another patient at 0830: At 0900 you document: 01-01-29 0830: Ate 100% of breakfast: _______________________Jane Doe RN NARRATIVE DOCUMENTATION FORMATS Focus charting (DAR) When in doubt DAR IT OUT! Data, action, response D = S/O data A = What did you do R = How is the patient NOW CHARTING BY EXCEPTION Charting by exception (CBE) in the EHR Focuses on documenting deviations from facility definitions of normal physiological and psychological assessment findings; Positives Reduces documentation time Negatives Patient problems distributed in different areas of chart  Abdomen: soft, flat, bowel sounds normoactive x 4 quadrants last bowel movement occurred CHARTING in past 48 hours BY EXCEPTION If this data describes your patient you click on it, if it does not you have to provide a narrative explanation of what is different and what you DID about the difference  The case management model of delivering care incorporates an interprofessional approach to patient CRITICAL care PATHWAYS Critical pathways are interprofessional care plans  Unexpected outcomes, unmet goals, and not done interventions within the critical pathway time frame are called negative variances. CRITICAL PATHWAY Based on Evidence and Best Practice to expedite facility based patient care: Time in to Time out is consistent for all patients and facilities for reimbursement: REPORTING Telephone Providers Situation-background-assessment- recommendation (SBAR) Provide following data to RN Current vital signs including Pulse ox and assessment data of body system or issue of concern Read-back orders  UNEXPECTED OCCURRENCE REPORTS/ INCIDENT REPORTS Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient DO NOT DOCUMENT AN OCCURRENCE REPORT Completed/Filed IN THE PATIENT RECORD: Document goes to Nurse Manager, Provider, Facility Risk Manager Why? Examples: patient falls, needle stick injuries, medication administration errors, omission of ordered therapies, and circumstances that lead to injury or to risk for patient or staff injury.  UNEXPECTED EVENTS OCCURRENCE REPORT PATIENT RECORD Pt found on floor next to bed Pt found on floor next to bed sitting upright with right and left sitting upright with right and left legs extended. Alert and legs extended. Alert and oriented x 3. Moving all oriented x 3. Moving all extremities. No visible injuries: “ extremities. No visible injuries: “ I just slipped, I don’t think I hurt I just slipped, I don’t think I hurt myself, I should have called for myself, I should have called for help.” help.” Dr. Smith called to see patient. Dr. Smith called to see patient. Room mate in room – Name Room mate XX stated, “I saw the whole thing, I told him to call for  Use data from the EHR to promote CLINICAL safe, high-quality patient care DECISION resulting in positive patient outcomes. SUPPORT Used to reduce patient risks. SYSTEM NURSING INFORMATION SYSTEMS (NIS) THAT PROVIDE CLINICAL DECISION SUPPORT Clinical decision support systems Used to support nurse’s clinical decision making Two designs Nursing Process Design Protocol or Critical Pathway Design  Based on “rules” and “if-then” statements Links information entered by the CLINICAL nurse/providers DECISION SUPPORT Produces alerts, warnings, or other SYSTEM information for the user. Example: support system notifies health care providers of patient allergies This enhances patient safety during the medication ordering process  REPORTED ADVANTAGES OF EHR Increased time to spend with patients Access to information Enhanced quality of documentation Reduced errors of omitting data Reduced hospital costs consistent data collection and standards Critical Pathways Increased nurse job satisfaction Compliance with accrediting agencies Common clinical database HIPPA AND THE EHR Computerized documentation has legal risks. Protection of YOUR Password is a top priority Tap In and Tap Out when you are not in front of the screen. Log In and Log Out when you are not in front of the screen. To protect patient privacy, health care agencies track who accesses patient records and when they access them. HIPPA AND THE EHR Printing information from a patient’s record is a possible risk for unauthorized release of information All papers containing patient information must be destroyed before you leave the facility QUESTIONS