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documentation
foundations exam 3
| Question | Answer |
|---|---|
| examples of documentation | written or electronic, legal record, all pertinent interactions |
| what is the medical record? | compilation of the patient's health information, legal document |
| Who is the paper "owned" by? | the hospital |
| Who is the content "owned" by? | the patient |
| Health Insurance portability and accountability act (HIPPA) of 1996 | if a health institution wants to release a patient's health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization |
| exceptions to HIPPA | public health activities, law enforcement, deceased individuals |
| Health information technology for economic and clinical health (HITECH) act goal | promote the meaningful use of health information technology (Electronic health records (EHRs)) |
| How does the HITECH act improve quality, safety, and efficiency? | through information sharing |
| How does the HITECH act protect patient privacy and security? | through digital security |
| HITECH act has strengthened... | HIPPAA rules- penalties for data breaches, required notification of patients if there is a breach |
| HIPPA established patient rights to: | see and copy their health records, choose how to receive this copy, update their chart, obtain a list of the disclosures |
| Who uses the medical record? | health care personnel, regulatory agencies, insurance companies, researchers, patient |
| What information is confidential? | all information about patients written on paper, spoken aloud, saved on computer |
| Examples of confidential information | name, address, phone, fax, social security number, reason the person is sick, treatments patient receives, information about past health conditions |
| potential breaches in confidentiality | displaying info on a public screen, sending confidential emails via public networks, sharing printers, discarding copies of patient info, overheard conversations, faxing confidential info to unauthorized persons, sharing confidential info on social media |
| incidental disclosure of PHI | a secondary disclosure that cannot reasonably be prevented, is limited in nature, and occurs as a by-product of an otherwise permitted use or disclosure of PHI |
| examples of incidental disclosures that are permitted | sign in sheets, placing patient charts outside of exam rooms, white boards, calling out names in waiting room, leaving appointment reminder voicemails |
| Nurses may unintentionally violate HIPPA by posting: | patient photos or details, stories with identifiable information, comments in private groups that can be traced |
| examples of violations regarding HIPPA and social media | sharing pt images or x rays without consent, discussing pt conditions in public posts, "before and after" photos without full de-identification |
| consequences of violating HIPPA | job termination, fines up to $50,000 per violation, loss of nursing license or certification |
| best practices regarding HIPPA | never post patient information, avoid discussing workplace incidents, follow social media policies |
| What does HIPPA specify? | 18 identifiers that make health information protected |
| Obvious parts of HIPPA | patient name, DOB |
| Not obvious parts of HIPPA | vehicle identifiers, device serial numbers, full-face photographic images |
| When is it considered a HIPPA violation on social media? | when any identifiers are shared in a post, picture, or video without explicit, written consent from the patient |
| A violation of HIPPA does not require... | the use of a patient's name; a breach can occur if enough information is shared to reasonably identify the patient |
| Is the specific platform where the information was shared relevant? | no |
| Who decides what to chart and what format? | professional standards, health care personnel, governmental agencies, accrediting bodies |
| all documentation must be... | complete, concise, timely, accurate, factual "unless" quotes the patient stated, secure, confidential, legally sound and meet established standards |
| content- guidelines | record observations, not interpretations, avoid generalizations, document assessments and interventions in a chronological orders, know professional standards and institutional policies when documenting, document both treatments and failure to treat |
| If you forget to document something... | record it as soon as you can, following the procedures for making late entries |
| what should you indicate when documenting? | the date and both the time the entry was written and the time of pertinent observations and interventions |
| Document nursing interventions as closely as possible to... | the time of their execution |
| When should you never document interventions? | before carrying them out |
| When do we chart? | upon admission, transfer to another unit, and discharge, shift assessment, when a procedure is performed, upon receiving a patient postop, upon communicating w/ health care providers regarding critical patient information, any change in pt status |
| format for paper guidelines | use app. form, legibly w/ dark black ink, never skip lines, draw line thru spaces, use accepted terms, abbrevs., symbols; sign first initial last name, title, no erasers/ whiteout, each page w/ pts name, id; single line, write error and initial mistakes |
| correcting errors | follow the correct protocol of your institution for correcting errors; even if you delete information, it still can be retrieved from the computer by the IT people |
| How do I correct a computer charting error? | correcting depends on the EMR system being used- consult with your facility's policy and procedures |
| How do I correct a charting error on paper records? | draw one line through the error (it should remain readable), date and initial the correction |
| How do I correct a charting error on electronic medical records? | make a new entry with today's date and time, stating your name and that you are correcting an error in a previous entry; give the date and time of the previous entry; enter the corrected data or explanation |
| Patients have an ethical and legal right to... | health privacy |
| All documents in a public area should have what? | a cover over them |
| protecting electronic medical records | create a secure password, never give out password or electronic signature to anyone, never leave the computer unattended if you are logged on, never send protected health information by email |
| documentation charting formats | narrative notes, charting by exception, focus charting (data, action, response), SOAP notes |
| narrative notes | nurse describes in their own terms the patient's assessment, interventions and response |
| cons of narrative notes | time consuming, difficult to read, difficult to find specific information |
| charting by exception | guidelines define specific and concise "normal assessments and expected outcomes" |
| narrative charting is done only on? | abnormal findings |
| pros of charting by exception | decreases charting time, easier to find significant data |
| cons of charting by exception | limited in providing necessary documentation to prove high quality of nursing care |
| SOAP notes | subjective, objective, assessment, plan |
| SOAP: subjective | what the patient states, cannot be measured (pain, nausea, dizziness) |
| SOAP: objective | measurable, vital signs, physical assessment |
| SOAP: assessment | what is wrong with the patient, based on subjective and objective assessments (combines the information) |
| SOAP: plan | plan of care/ treatment, patient education, physician consult |
| What stands out about poor quality charting? | inaccurate, repetitious, omissions, "illegal abbreviations", judgmental terms, general terms |
| The joint commission official "Do not use" list | related to medications: spell out units (not u), spell out daily (not qd), no trailing zero (not 1.0 mg, just 1 mg), always use leading zero (0.1mg) |
| what are the results of poor charting? | lower the quality of patient care, reflect poorly on the individual and nursing profession, legal issues |
| What makes charting so difficult? | computer issues, interruptions, prioritizing patient needs versus documentation |
| How can I improve my charting? | solicit feedback, document as soon as possible, document all calls (made or received) |
| How should RN document verbal and telephone orders? | write it out, read it back, note the modality (phone, verbal), write the full name of physician, sign or e-sign the orders with name and title and "read back" |
| Charting medical errors | exact details should always be included in the chart, notification of patient and family completed and charted- get the TEAM together, never chart that an occurrence report was completed |
| What is an incident report used to document? | an occurrence out of the ordinary that could or has caused patient harm |
| what is an incident report utilized for? | quality improvements |
| What does an incident report provide? | exact details (accurate and objective), witnesses, safety measures in place to prevent, notification of physician, hospital or unit supervisor, follow up measures, effectiveness of interventions, |
| Is an incident report part of a patients medical record? | no |
Created by:
camrynfoster