Foundations Chapter 5 PDF

Online Video: Confidentiality CHAPTER 5 UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT ELEMENTS OF DOCUMENTATION SECTION: MANAGEMENT OF CARE...

Online Video: Confidentiality CHAPTER 5 UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT ELEMENTS OF DOCUMENTATION SECTION: MANAGEMENT OF CARE Factual: Subjective and objective data Information Nurses should document subjective data as direct CHAPTER 5 quotes, within quotation marks, or summarize and Technology identify the information as the client’s statement. Subjective data should be supported by objective data so charting is as descriptive as possible. Objective data should be descriptive and should include The chart or medical record is the legal what the nurse sees, hears, feels, and smells. Document without derogatory words, judgments, or opinions. record of care. Document the client’s behavior accurately. Instead of writing “client is agitated,” write “client pacing back The medical record is a confidential, permanent, and forth in the room, yelling loudly.” and legal document that is admissible in court. Accurate and concise:Document facts and information Nurses are legally and ethically responsible for precisely (what the nurse sees, hears, feels, smells) without any interpretations of the situation. Unnecessary ensuring confidentiality. Only health care words and irrelevant detail are avoided. Exact providers who are involved directly in a client’s measurements establish accuracy. Only abbreviations and symbols approved by The Joint Commission and the care can access that client’s medical record. facility are acceptable. Nurses document the care they provide as Complete and current:Document information that is comprehensive and timely. Never pre‑chart an assessment, documentation or charting, and it should reflect intervention, or evaluation. the nursing process. Organized:Communicate information in a logical sequence. There is a rapidly growing trend for maintaining medical records electronically, which creates LEGAL GUIDELINES Begin each entry with the date and time. challenges in protecting the privacy and safety Record entries legibly, in non-erasable black ink, and do of health information. not leave blank spaces in the nurses’ notes. Do not use correction fluid, erase, scratch out, or Information to document includes assessments, blacken out errors in the medical record. Make corrections promptly, following the facility’s procedure medication administration, nursing actions, for error correction. treatments and responses, and client education. Sign all documentation as the facility requires, generally with name and title. Documentation should reflect assessments, DOCUMENTATION interventions, and evaluations, not personal opinions or criticism about client or other health care Documentation is a standard for many accrediting professionals’ care. agencies, including The Joint Commission (formerly JCAHO). The Joint Commission mandates the use of computerized databases to expedite the accreditation process. Health care facilities use the computerized data DOCUMENTATION FORMATS for budget management, quality improvement programs, Flow charts show trends in vital signs, blood glucose research, and many other endeavors. levels, pain level, and other frequent assessments. Purposes for medical records include communication, Narrative documentation records information as a legal documentation, financial billing, education, sequence of events in a story‑like manner. research, and auditing. The purpose of reporting is to provide continuity of care Charting by exceptionuses standardized forms that and enhance communication among all team members identify norms and allows selective documentation of who provide care to the same clients, thus promoting deviations from those norms. client safety. Problem‑oriented medical recordsare organized by Nurses should conduct reporting in a problem or diagnosis and consist of a database, problem confidential manner. list, care plan, and progress notes. Examples include SOAP, PIE, and DAR. (5.1) FUNDAMENTALS FOR NURSING CHAPTER 5 Information Technology 21  Electronic health recordsare replacing manual formats in Transfer (hand‑off) reports many settings. These should include demographic information, medical Advantages include standardization, accuracy, diagnosis, providers, an overview of health status confidentiality, easy access for multiple users, providing (physical, psychosocial), plan of care, recent progress, any ease in maintaining ongoing health record of client’s alterations that might become an urgent or emergent condition, and rapid acquisition and transfer of clients’ situation, directives for any assessments or client care information. essential within the next few hours, most recent vital Challenges include learning the system, knowing how signs, medications and last doses, allergies, diet, activity, to correct errors, and maintaining security. specific equipment or adaptive devices (oxygen, suction, Documentation rules and formats are similar to those wheelchair), advance directives and resuscitation status, for paper charting. discharge plan (teaching), and family involvement in care and health care proxy. REPORTING FORMATS Incident reports (unusual occurrences) Change‑of‑shift report Incident/variance reports are an important part of a facility’s quality improvement plan. Nurses give this report at the conclusion of each shift to An incident is the occurrence of an accident or an the nurse assuming responsibility for the clients. unusual event. Examples of incidents are medication Formats include face-to-face, audiotaping, or errors, falls, omission of prescription, and needlesticks. presentation during walking rounds in each client’s Document facts without judgment or opinion. room (unless the client has a roommate or visitors Do not refer to an incident report in a client’s are present). medical record. An effective report should: Incident reports contribute to changes that help improve ◯ Include significant objective information about the health care quality. client’s health problems. ◯ Proceed in a logical sequence. ◯ Include no gossip or personal opinion. ◯ Relate recent changes in medications, treatments, INFORMATION SECURITY procedures, and the discharge plan. Mandatory adherence with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) began Telephone reports in 2003 to help ensure the confidentiality of health information. Telephone reports are useful when contacting the provider A major component of HIPAA, the Privacy Rule, or other members of the interprofessional team. promotes the use of standard methods of maintaining It is important to: the privacy of protected health information (PHI) among ◯ Have all the data ready prior to contacting any health care agencies. member of the interprofessional team. It is essential for nurses to be aware of clients’ ◯ Use a professional demeanor. rights to privacy and confidentiality. Facilities’ ◯ Use exact, relevant, and accurate information. policies and procedures help ensure adherence with ◯ Document the name of the person who made the HIPAA regulations. call and to whom the information was given; the time, content of the message; and the instructions or Privacy rule information received during the report. The Privacy Rule requires that nurses protect all written Telephone or verbal prescriptions and verbal communication about clients. Components of the Privacy Rule include the following. It is best to avoid these, but they are sometimes necessary Only health care team members directly responsible for during emergencies and at unusual times. a client’s care can access that client’s record. Nurses Have a second nurse listen to a telephone prescription. cannot share information with other clients or staff not Repeat it back, making sure to include the medication’s caring for the client. name (spell if necessary), dosage, time, and route. Clients have a right to read and obtain a copy of their Question any prescription that seems inappropriate for medical record. the client. Nurses cannot photocopy any part of a medical record Make sure the provider signs the prescription in except for authorized exchange of documents between person within the time frame the facility specifies, facilities and providers. typically 24 hr. Staff must keep medical records in a secure area to prevent inappropriate access to the information. They cannot use public display boards to list client names and diagnoses. Electronic records are password‑protected. The public cannot view them. Staff must use only their own passwords to access information. 22 CHAPTER 5 Information Technology CONTENT MASTERY SERIES  Nurses must not disclose clients’ information to unauthorized 5.1 Problem‑oriented medical records individuals or family members who request it in person or by SOAP PIE DAR focus charting telephone or email. S Subjective data P Problem ◯ Many hospitals use a code system to O Objective data I Intervention D Data identify those individuals who can A Assessment E Evaluation A Action receive information about a client. includes a nursing diagnosis based on R Response ◯ Nurses should ask any individual the assessment inquiring about a client’s status for P Plan the code and disclose information only when the individual can give the code. Communication about a client should only take place in a private setting where unauthorized Social media precautions individuals cannot overhear it. Know the implications of HIPAA before To adhere to HIPAA regulations, each facility has specific using social networking sites for school‑ or policies and procedures to monitor staff adherence, work‑related communication. technical protocols, computer privacy, and data safety. Become familiar with your facility’s policies regarding the use of social networking. Information security protocols Do not use or view social networking media in Log off from the computer before leaving the clinical settings. workstation to ensure that others cannot view protected Do not post information about your facility, clinical health information on the monitor. sites, clinical experiences, clients, and other health care Never share a user ID or password with anyone. staff on social networking sites Never leave a medical record or other printed or written Do not take pictures that show clients or their PHI where others can access it. family members. Shred any printed or written client information for reporting or client care after use. FUNDAMENTALS FOR NURSING CHAPTER 5 Information Technology 23  Application Exercises 1. A nurse is preparing information for a change‑of‑shift 4. A nurse is discussing occurrences that require report. Which of the following information completion of an incident report with a newly licensed should the nurse include in the report? nurse. Which of the following should the nurse A. Input and output for the shift include in the teaching? (Select all that apply). B. Blood pressure from the previous day A. Medication error C. Bone scan scheduled for today B. Needlesticks D. Medication routine from the medication C. Conflict with provider and nursing staff administration record D. Omission of prescription E. Missed specimen collection of a prescribed laboratory test 2. A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should 5. A nurse is receiving a provider’s prescription by the nurse manager include? (Select all that apply.) telephone for morphine for a client who is reporting A. A single electronic records password is moderate to severe pain. Which of the following provided for nurses on the same unit. nursing actions are appropriate? (Select all that apply.) B. Family members should provide a code prior A. Repeat the details of the prescription to receiving client health information. back to the provider. C. Communication of client information B. Have another nurse listen to the can occur at the nurses’ station. telephone prescription. D. A client can request a copy of their medical record. C. Obtain the provider’s signature on E. A nurse can photocopy a client’s medical the prescription within 24 hr. record for transfer to another facility. D. Decline the verbal prescription because it is not an emergency situation. E. Tell the charge nurse that the provider has 3. A charge nurse is reviewing documentation with prescribed morphine by telephone. a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client’s record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of the shift to document. Active Learning Scenario A nurse is introducing a group of newly licensed nurses to the various approaches to problem‑oriented documentation. Use the ATI Active Learning Template: Basic Concept to complete this item. UNDERLYING PRINCIPLES: List three common methods of problem‑oriented charting with definitions of their acronyms. 24 CHAPTER 5 Information Technology CONTENT MASTERY SERIES