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doc and confidential
legal & ethical issues in nursing chap 8
| Question | Answer |
|---|---|
| Purpose of Medical Records | Assist with patient care aspects, Document course of patient’s medical evaluation treatment and change in condition |
| Purpose of Record Keeping | Patient identification, Medical support for diagnosis |
| Justification of therapies used, Documentation of what transpired | |
| Content of Medical Records | Personal data, Financial data, Medical data |
| Effective Documentation | Make an entry for every observation |
| Follow up as needed | Merely charting changes in patient status may not be adequate |
| Read prior nurses’ note entries before giving care | Helps to identify if the patient condition has changed |
| Effective Documentation | Always make an entry, even if it is late, Do not try to squeeze the information into a small space or along the margins of the chart |
| Effective Documentation | Make a chart entry after the event, Never chart in advance, Write the actual, not the expected |
| Effective Documentation | Be realistic and factual, Chart exactly what happened |
| Computerized Charting | Increases accurate recording of facts, Issues of concern |
| Charting by Exception | Documentation of only significant or abnormal findings |
| Alteration of Records | Minor errors in spelling, notations of data, incorrect phraseology |
| Retention of Records | Varies by state law either by statute of limitations for lawsuits or 5 years, Most save records for longer periods of time |
| Ownership of the Record | Hospital is the rightful owner of the entire record as a record of business of the institution |
| Access to Medical Records | Most states require record to be completed, Legal guardians may obtain access for incompetent patients |
| Incident, variance, situational, or unusual occurrence reports | |
| Risk management or quality assurance effort | Mandated by JCAHO as a method to review or evaluate patient care, Serve to aid hospital attorney in planning defense strategy |
| Faxing of Medical Records | Issue with patient’s right to privacy, HIPAA standards, Faxed only if urgently needed, Must have a signed release form |
| Health Insurance Portability and Accountability Act of 1996 (HIPAA) | Mandates the development of a centralized electronic database containing all health records for every patient in the United States |
| Information given to governmental agencies, federal and state | Vital statistics, Child abuse, Elder abuse, Public health, Wounds |
| Substance Abuse Confidentiality | Special federal rules deal with confidentiality in these cases |
Created by:
rcline@
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