Records Management Nursing Leadership and Management PDF

Records Management Nursing Leadership and Management Fajardo, Ruth Angela Fesalboni, Ace Muñoz, Kimberly G. Pajar, Charlene Mae Ponceca, Natalie Cole G. Raymundo, Regine Salipot, Rayolen Supremo, John Klyde...

Records Management Nursing Leadership and Management Fajardo, Ruth Angela Fesalboni, Ace Muñoz, Kimberly G. Pajar, Charlene Mae Ponceca, Natalie Cole G. Raymundo, Regine Salipot, Rayolen Supremo, John Klyde Group 4 Topics Records Management A. Data Privacy Protocols in Data Safekeeping and Release of Records 1. Sentinel Events 2. Anecdotal 3. Incident Report 4. KARDEX 5. Patient’s Charts / Records 6. 201 File B. Roles of the Nurse in Records Management  TERMINOLOGIES Records: are critical documents that capture the history, operations, and communications within healthcare settings. Include patient medical records, administrative reports, staff schedules, and other essential documentation that supports clinical and managerial decision-making. Management: coordination and oversight of resources, including personnel, information, and processes, to ensure the delivery of high- quality patient care. Includes strategic planning, organizing workflows, leading teams, and controlling healthcare operations to meet both clinical and organizational goals.  Surgical Errors Medication Errors Records Management Is the systematic control of the creation, receipt, maintenance, use, and disposal of records. It ensures that the necessary information Maternal/Neonatal Suicide is available when needed, enhances the Death efficiency and accountability of healthcare operations, and helps maintain compliance with legal and regulatory requirements. Importance of Records Management 1. Accurate and timely records allow for better decision-making, continuity of care, and improved patient outcomes. 2. Proper records management ensures that healthcare organizations comply with legal, ethical, and regulatory standards, which is vital for patient safety and organizational integrity. 3. Efficient records management reduces duplication of efforts, streamlines processes, and helps in the effective use of resources. Improves Patient Ensures Enhances Efficiency Care Compliance  IMPORTANCE 5. Well-maintained records ensure clear 4. Comprehensive communication records provide nursing among healthcare leaders with the professionals, necessary information fostering to make informed collaboration and decisions regarding minimizing errors. staffing, resource allocation, and policy Supports Leadership Facilitates development. Decisions Communication  A. Data Privacy in Data Safekeeping and Release of Records Data Privacy: protection of personal information from unauthorized access, use, disclosure, alteration, or destruction. Safeguarding sensitive patient data, including medical records, personal identifiers, and any information that could compromise the confidentiality and integrity of the individual's health information. Data Safekeeping: secure storage and protection of data to prevent loss, theft, or unauthorized access. Use of physical and digital security measures, such as encryption, secure servers, and restricted access, to ensure that data remains intact and confidential. Release of Records: process of providing access to or sharing records with authorized individuals or entities. The controlled release of patient medical records to healthcare providers, insurance companies, or other parties, often governed by legal and regulatory frameworks to protect patient privacy.  1. Implement Strong Access Controls How to ensure data privacy in 1. Restrict access to sensitive data only to authorized personnel. Use role- data safekeeping based access controls (RBAC) and ensure that employees have access and release of only to the information necessary for their role. records?  2. Use Encryption How to ensure data privacy in data safekeeping and release of 2. Encrypt data both at rest and in transit to protect it from unauthorized access during storage and transmission. records?  3. Regular Audits and Monitoring How to ensure data privacy in 3. Conduct regular audits of data access data safekeeping and release of and use, monitor for any unauthorized access attempts, and ensure compliance records? with data privacy policies.  4. Employee Training How to ensure data privacy in 4. Provide regular training for all staff on data safekeeping and release of data privacy practices, including how to handle, store, and release records securely. Emphasize the importance of following protocols to prevent data breaches. records?  5. Secure Data Disposal How to ensure data privacy in 5. Implement secure methods for data safekeeping and release of disposing of data that is no longer needed, such as shredding physical documents and securely deleting digital files, to prevent unauthorized recovery. records?  7. Consent and Authorization How to ensure data privacy in 7. Ensure that patient consent is obtained data safekeeping and release of before the release of records and that the release is limited to the information necessary for the purpose specified by the patient. records?  6. Legal and Regulatory Compliance How to ensure data privacy in 6. Adhere to all relevant legal and data safekeeping and release of regulatory requirements for data privacy, such as HIPAA in the U.S., ensuring that policies and practices align with these standards. For the Philippines it’s Data Privacy Act of 2012 (Republic Act No. 10173). records? Importance of Data Privacy in Data Safekeeping and Release of Records Ensuring data privacy in the safekeeping and release of records is not just a legal requirement but a critical component of effective healthcare delivery, protecting both patients and the organization from the risks associated with data breaches and unauthorized disclosures. 1. Ensuring data privacy helps maintain the confidentiality of patient information, which is fundamental to the trust between patients and healthcare providers. Importance of Data Privacy in Data Safekeeping and Release of Records 2. Strong data privacy practices minimize the risk of data breaches, which can lead to identity theft, financial loss, and damage to the organization's reputation. 3. Adhering to data privacy laws and regulations helps healthcare organizations avoid legal penalties and ensures they meet ethical obligations to protect patient information. Importance of Data Privacy in Data Safekeeping and Release of Records 4. Patients are more likely to share sensitive information with healthcare providers when they trust that their data will be kept private and secure, which is crucial for accurate diagnosis and effective treatment. 5. Proper data privacy practices contribute to the overall integrity and credibility of a healthcare organization, reinforcing its commitment to ethical standards and quality care.  Virtual Remote Monitoring Consultations Devices Sentinel Events A sentinel event is a patient safety event that reaches a patient and results in any of the following: death, permanent harm, severe temporary harm and intervention required to AI-Driven Triage Telehealth Platforms sustain life. Systems  Surgical Errors Medication Errors Sentinel Events A sentinel event is any unanticipated safety event in a healthcare setting that reaches a patient and results in any of the following: death, permanent harm, severe temporary Maternal/Neonatal Suicide harm and intervention required to sustain life, Death not related to the natural course of the patient's illness by The Joint Commission. Types of Sentinel Events Serious reportable events can be classified into the following categories: 1. Surgical 2. Device/product 3. Care management 4. Environmental 5. Patient protection 6. Radiologic event 7. Criminal events  Why do Sentinel Events Occur? Systemic problems rather than the mistake or failure of a single individual. 1. Inadequate communication among healthcare providers is the number-one root cause of sentinel events.  2. Incorrect assessment of a patient’s condition 3. Inadequate leadership, orientation, or training. Managing Entire healthcare system Sentinel Events 1. Stabilize the patient 2. Disclose the event to the patient and family 3. Provide support for the family and staff involved 4. Notification to the hospital leadership Specific patient situation 5. Immediate investigation (patient’s safety and well-being) 6. Comprehensive systematic review 7. Root cause analysis (RCA) for identifying the causal and contributory factors. 8. Strong corrective actions to eliminate the root cause and prevent similar future events 9. Establish a timeline for the implementation of corrective actions 10. System improvement  ANECDOTAL Anecdotal is information derived from personal experience or observation and is used to learn about experiences, products, and to help prove a point. It is not scientific evidence, which can be verified objectively. Contents of an anecdotal Contents of an anecdotal generally includes several categories: 1. Description of the Case 2. Observation 3. Contextual Information 4. Conclusion How are anecdotal being recorded and managed Providers document individual experiences and observations during treatment, noting any unusual outcomes or responses. These observations may be compiled into case series or shared informally among colleagues. The aim is to capture insights that may inform future research or clinical practice. Privacy considerations Privacy considerations for anecdotal information include ensuring patient confidentiality by anonymizing data, avoiding identifiable details, and adhering to regulations like HIPAA. Providers must obtain patient consent before sharing anecdotes and handle sensitive information with care to prevent breaches of personal health information. ANECDOTAL  INCIDENT REPORT An incident report is a formal documentation of any unexpected or unusual event that occurs within a workplace or healthcare setting. It captures details such as the nature of the incident, the people involved, the time and location, and the immediate actions taken. In healthcare, incident reports are crucial for identifying potential risks and preventing future occurrences by allowing for the analysis of patterns or systemic issues. Contents of an Incident Report: Date and Time of Incident Location Description of the Incident Individuals Involved Type of Incident Immediate Actions Taken Outcome/Consequences Contributing Factors Recommendation/Preventive Measures Reporter’s Information Follow-up Actions How are incident report being recorded and managed Immediate Reporting: As soon as an incident occurs, the involved staff member or witness is required to complete an incident report, often using a standardized form or digital platform. The report should be filled out as soon as possible while details are still fresh. Submission: The completed report is submitted to a designated supervisor, manager, or risk management department. In digital systems, this may involve uploading the report to a centralized incident management system. Initial Review: The immediate supervisor or a designated safety officer reviews the report to assess the situation, confirm details, and determine the severity of the incident. This review may involve interviews with involved parties or witnesses. Record Retention: Reports are stored according to organizational policies, which often align with legal or regulatory requirements for record retention. How are incident report being recorded and managed Corrective Measures: Based on the findings from the review or investigation, corrective actions are implemented to address the root causes of the incident. This might include changes to protocols, additional staff training, or physical modifications to the environment. Monitoring: The effectiveness of the corrective actions is monitored over time to ensure that similar incidents do not recur. This may involve follow-up audits or reviews. Internal Reporting: Summaries of incidents and actions taken are often reported to management, safety committees, or other relevant bodies within the organization. This helps in keeping all stakeholders informed and engaged in the continuous improvement process. Policy Updates: Incident data is used to refine and update organizational policies, procedures, and training programs, fostering a culture of safety and continuous improvement. Privacy Considerations 1. Confidentiality of Information 2. Compliance with Legal and Regulatory Standards 3. Anonymization and De-identification 4. Secure Storage and Transmission 5. Transparency and Informed Consent  KARDEX A documentation system that provides a concise overview of each patient's information, typically maintained on durable card stock. It serves as a quick reference for nursing staff, summarizing critical patient data that is updated with each shift change. The term "Kardex" originated from a trademarked brand name and has become synonymous with similar paper-based record-keeping systems in healthcare settings Contents of a Kardex The contents of a Kardex generally include: Patient Demographics Current Medications Allergies Activity Level Personal Care Needs Dietary Restrictions Treatment Schedule Care Plans How are KARDEX being recorded and managed Creation: Upon patient admission, a Kardex card is created, summarizing all relevant information. Updates: Nurses update the Kardex at every shift change, ensuring that any new information or changes in patient status are accurately reflected. Centralized Location: Kardexes are typically kept at the nursing station for easy access by all nursing staff. Electronic Versions: Some facilities have transitioned to electronic Kardex systems, allowing for easier updates and access to patient information Privacy considerations Confidentiality: Since Kardexes contain sensitive patient information, they are not part of the official medical record. After a patient is discharged, the Kardex is shredded to protect confidentiality. Access Control: Only authorized nursing staff should have access to the Kardex. Non-Official Record: The Kardex is meant for internal use among nursing staff and should not be used as a substitute for formal documentation in medical records EHR  Patient Chart\Records A patient's chart, also known as a medical record, is a comprehensive documentation of a patient's medical history and care. It serves as an essential tool in healthcare settings, capturing every aspect of the patient's health status, treatments, and interactions with healthcare providers. Contents of a Patients Chart The contents of a Patient's Chart generally include: Personal Information. Medical History. Medications frequencies. Progress Notes. Lab Results and Diagnostic Tests. Vital Signs Treatment Plans and Orders Consent Forms Discharge Summaries How are patient’s charts /record being recorded and managed 1 2 Paper-Based Records: Electronic Health Records: Traditionally recorded manually Digital versions that allow real-time and stored in secure filing systems, access to patient data, improving but can be cumbersome to accuracy, efficiency, and manage. integration with other healthcare systems. Privacy considerations: 1. Data Security: Providers must implement strict security measures to prevent unauthorized access. 2. Informed Consent: Patients must give explicit consent for the sharing and use of their medical information. 3. Limited Access: Only authorized personnel should have access to patient data. 4. Data Breach Protocols: Institutions must have protocols in place to address potential data breaches. Advantages and Disadvantages Advantages: Disadvantages: Continuity of care High Cost Improved Accuracy Training Requirements Enhanced Communication Privacy risk Streamlined Workflow Technical Dependence  201 FILE A 201 file is a comprehensive and confidential record of an employee's employment history within an organization. This file is typically used in the Philippines, especially in government and private sectors, to document an employee's career from hiring to termination or resignation. It contains all relevant documents and information pertaining to the employee's tenure with the company.How Records Are Managed Content of 201 File A 201 file may include, the following documents: 1. Personal Information Birth Certificate Educational credential 2. Employment Documents cover letter 3. Resignation or Termination Employment certificate  How a 201 File is Recorded and Managed Recording The Human Resources department is responsible for creating and maintaining the 201 file. HR collects all documents, which are organized and stored in the 201 file. Management Physical Files: Traditionally, the HR department maintains 201 physical files in a locked filing cabinet. Digital Files: Access controls are in place on firm servers where these electronic records are safely kept, guaranteeing that only authorized personnel can access or modify the data.  Privacy Considerations Confidentiality: The contents of a 201 file are highly confidential. Employee, and certain company officials are typically allowed to access the file. Data Protection: Organizations must comply with data protection laws. This includes securing the information from unauthorized access, leaks, or breaches and ensuring that the data is only used for legitimate purposes.  Privacy Considerations Access and Consent: Employees have the right to access their 201 file to review the contents or request corrections to inaccurate information. However, any sharing of the 201 file outside the organization typically requires the employee's consent. Retention and Disposal: Once an employee leaves the company, their 201 file is typically retained for a certain period as required by law or company policy. The file must be securely disposed of to protect the employee’s privacy. Roles of the Nurse in Records Management How Records Are Managed 1. Data Entry: Manual and Electronic Methods: Accurate data entry is essential for maintaining the integrity of patient records and supporting clinical decision-making. 2. Data Storage: Physical Records: Secure storage in locked file rooms or cabinets. Digital Records: Use of encrypted databases and secure access protocols. How Records Are Managed 3. Data Retrieval: Access Control: Authorized personnel have access to patient records based on their role and need, ensuring that information is accessed and used appropriately. 4. Data Sharing: Controlled Disclosure: Sharing information in a manner that respects patient privacy and complies with legal and organizational policies. 5. Data Archiving: Retention Policies: Records are archived according to legal requirements, with protocols for secure destruction once the retention period expires. Nurses’ Roles in Records Management 1. Documentation: Accurate Entry: Nurses must ensure all patient information is recorded accurately and promptly. This includes detailed records of medical history, treatments, and patient responses. Legal Compliance: Proper documentation is necessary to comply with legal standards and to ensure that all records meet regulatory requirements. 2. Maintaining Confidentiality: Data Protection: This involves following strict confidentiality protocols and using secure methods for handling records. Secure Storage: Physical records must be kept in locked, secure locations, while electronic records require encryption and secure access controls.  Nurses’ Roles in Records Management 3. Updating and Managing Records: Continuous Updates: Regular updates to patient records are essential to reflect changes in patient condition, treatments, and medications. Accuracy Checks: Nurses need to review and verify records regularly to ensure all information is accurate and complete. 4. Coordination with Other Healthcare Providers: Information Sharing: Secure sharing of patient information among healthcare providers ensures coordinated care and effective treatment planning. Nurses’ Roles in Records Management 5. Utilizing Electronic Health Records (EHRs): Data Integrity: Nurses must ensure that the information entered into EHRs is reliable and reflects the true state of the patient's health. 6. Education and Training: Guiding New Staff: Experienced nurses train new staff on documentation practices and system usage to ensure consistent and accurate record-keeping. Patient Education: Educating patients about their rights concerning their medical records and the importance of accurate health information.  Conclusion Effective records management in healthcare is essential for ensuring patient safety, maintaining data privacy, and supporting accurate and accessible documentation. Nurses play a crucial role in managing various records, such as incident reports, patient charts, and staff files, while adhering to privacy protocols to safeguard sensitive information. This ensures high-quality care and legal compliance within the healthcare system. Thanks! Do you have any question? Group 4