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Patient Safety, Communication and Recordkeeping/ HIPAA.

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Presentation on theme: "Patient Safety, Communication and Recordkeeping/ HIPAA."— Presentation transcript:

1 Patient Safety, Communication and Recordkeeping/ HIPAA

2 Objectives 1. Describe Patient Safety issues 2. Describe the rationale for documenting respiratory care activities. 3. List the elements of a patient medical record. 4. Identify five medical record documentation standards. 5. List respiratory care information commonly recorded in the medical record.

3 Objectives 6. Describe the rationale for the electronic medical record. 7. Define the concept of patient confidentiality. 8. Discuss things that the respiratory therapist can do to improve patient safety. 9. Discuss SBAR communication.

4 Patient Safety Quality care is vital as is patient safety. Aspects of patient safety include: Infection control/contamination control Risk of falls Risk of aspiration Medication and surgical mistakes Wrong patient/identification mistakes Medical equipment failure/mismanagement

5 Patient Safety Medical errors have been implicated in the premature deaths of 98,000 patients per year, accounting for between $17 and $29 billion in costs annually.

6 6 We know that patient safety is the bedrock of quality care Institute of Medicine: Quality Care

7 7 IOM elements of “Quality” Safe: avoiding injuries to patients from the care that is intended to help them Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse) Efficient: avoiding waste, in particular waste of equipment, supplies, ideas, and energy Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status Patient-Centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions “STEEEP” Framework outlined by the Institute of Medicine (“IOM”)

8 8 We preach “quality” but can we say we have a true “culture of safety” Culture “The way we do things around here” Safety Avoiding injuries from care intended to help patients


10 Types of error About half of the adverse events occurring among inpatients resulted from surgery. Others Complications from drug treatment therapeutic mishaps diagnostic errors were the most common non- operative events.

11 Types of error Cognitive errors--such as incorrect diagnosis or choosing the wrong medication-- more likely to have been preventable and more likely to result in permanent disability than technical errors.

12 Which patients are most at risk? Those undergoing cardiothoracic surgery, vascular surgery, or neurosurgery Those with complex conditions Those in the emergency room Those looked after by inexperienced doctors Older patients

13 How dangerous is health care? Less than one death per 100 000 encounters Nuclear power European railroads Scheduled airlines One death in less than 100 000 but more than 1000 encounters Driving Chemical manufacturing More than one death per 1000 encounters Bungee jumping Mountain climbing Health care

14 Why do errors happen? All humans make errors: indeed, “the ability to make mistakes” allows human beings to function Most of medicine is complex and uncertain Most errors result from “the system”--inadequate training, long hours, ampoules that look the same, lack of checks, etc Healthcare has not tried to make itself safe FUTURE: More accountability, hospital fines/costly lawsuits, readmission penalties…

15 Medical Information Management Documentation provides: o A reference on the status of the patient’s condition prior to intervention o A record of key steps with the provision of care o An account of the effectiveness of care o An opportunity to record recommendations or modifications to the care o A record of the educational materials provided to the patient o Ongoing needs and the discharge plan

16 Electronic Medical or Health Records Electronic medical record (EMR) and electronic health record (EHR) are two terms to describe computerized systems that track and record patient information electronically. The EMR/EHR: o Speeds entry o Improves the storage and retrieval of patient information o Improves the provision of care o Is designed to guide the clinician through an activity from start to finish o Incorporates data that are critical to the provision or evaluation of response to care

17 Electronic Medical or Health Records Drop-down lists help limit errors in data entry, provide consistency, and speed up the selection process. Hard stops require the therapist to enter data or complete the required field selection prior to progressing or committing the record to the EMR. An electronic signature is a method to allow practitioners to sign off on care rendered.

18 The Patient’s Medical Record Medical Record – “Chart” A documented account of the occurrences pertaining to the patient throughout his or her stay in a healthcare institution

19 The Patient’s Medical Record Medical Record – “Chart” It is the property of the institution and its contents are confidential and may not be read or discussed by anyone except those directly caring for the patient in a hospital or medical care facility.

20 The Patient’s Medical Record Medical Record – “Chart” It is a legal document and must be maintained by the healthcare institution for days, months, or years, in case it is needed in a court of law

21 The Patient’s Medical Record Components of the Medical Record Admission Sheet Records pertinent patient information (e.g., name, address, religion, nearest of kin), admitting physician, and admission diagnosis History and Physical Records the patient’s admitting history and physical examination as performed by the attending physician or resident

22 The Patient’s Medical Record Components of the Medical Record Physician’s Orders Records the physician’s orders and prescriptions Progress Sheet Commonly referred to as “progress notes” Keep a continuing account of the patient’s progress for the physician

23 The Patient’s Medical Record Components of the Medical Record Nurses’ Notes Describes the nursing care given to the patient, including the patient’s complaints (subjective symptoms), the nurses’ observations (objective signs), and the patient’s response to therapy Medication Admission Record “MAR” Notes drugs and IV fluids that are given to the patient

24 The Patient’s Medical Record Components of the Medical Record Vital Signs Graphic Sheet Records the patient’s temperature, pulse, respiration, and blood pressure over time I/O Sheet Records the patient’s fluid intake (I) and output (O) over time

25 The Patient’s Medical Record Components of the Medical Record Laboratory Sheet Summarizes the results of laboratory tests Consultation Sheet Records notes by specialty physicians who are called in to examine a patient to make a diagnosis

26 The Patient’s Medical Record Components of the Medical Record Surgical or Treatment Consent Records the patient’s authorization for surgery or treatment Anesthesia and Surgical Record Notes key events before, during, and immediately after surgery

27 The Patient’s Medical Record Components of the Medical Record Specialized Therapy Records Records specialized treatments or treatment plans and patient progress for various specialized therapeutic services (e.g., respiratory care, physical therapy) Specialized Flow Sheets Records measurements made over time during specialized procedures (e.g., mechanical ventilation, kidney dialysis)

28 Flow Sheets

29 The Patient’s Medical Record Legal Aspects of Recordkeeping Legally, documentation of care given to a patient means that care was given Legally, no documentation means that care was not given Lack of documentation can be interpreted as patient neglect

30 The Patient’s Medical Record General Rules for Medical Recordkeeping Entries should be printed or handwritten. After completing the account, sign the chart with the initial of first name, complete last name, and your title (CRT, RRT, Resp Care Student, etc.) Example: B. Kind, RRT Do Not Use ditto marks – “ “

31 General Rules for Medical Recordkeeping Do not erase! Erasures provide reason for questions if the chart is used in a court of law. If a mistake is made, a single line should be drawn through the mistake and the word “error” printed above it; the correction should be initialed Example:Respiratory Tx given at 10:00 10:30 The Patient’s Medical Record error

32 General Rules for Medical Recordkeeping Record after completing each task for the patient (never beforehand) and sign your name correctly after each entry Be exact in noting the time, effect, and results of all treatments and procedures Describe clearly and concisely observations and assessments, e.g., the character of breath sounds, percussion notes, secretions, etc. The Patient’s Medical Record

33 General Rules for Medical Recordkeeping Leave no blank lines in the charting Draw a line through the center of an empty line or part of a line. This prevents charting by someone else in an area signed by you Use the present tense. Never use the future tense, as in “Patient to receive treatment after lunch.” The Patient’s Medical Record

34 General Rules for Medical Recordkeeping Spell correctly If you are not sure about the spelling of a word, use a dictionary and look it up Use standard, hospital-approved abbreviations Do not make up your own The Patient’s Medical Record

35 The Problem-Oriented Medical Record A documentation format used by some healthcare institutions POMR contains the following: 1.The Database 2.The Problem List 3.The Plan 4.The Progress Note The Patient’s Medical Record

36 The Problem-Oriented Medical Record The Database Routine information about the patient General health history Physical examination results Results of diagnostic tests The Patient’s Medical Record

37 The Problem-Oriented Medical Record The Problem List A problem is something that interferes with a patient’s physical or psychological health or ability to function Problems are identified and listed, based on the information provided by the database The problem list is dynamic; new problems are added as they develop and others problems are removed as they are resolved The Patient’s Medical Record

38 The Problem-Oriented Medical Record The Progress Note Contain the findings (subjective and objective), assessment, plans, and orders of the doctors, nurses, and other practitioners involved in the care of the patient The format used in often referred to as SOAP S – subjective O – objective A – assessment P - plan The Patient’s Medical Record

39 Charting Using the SOAP Format Subjective Information obtained from the patient, his or her relatives, or a similar source Objective Information based on caregivers’ observations of the patient, the physical examination, or diagnostic or laboratory tests such as ABG or PFT Assessment The analysis of the patient’s problem Plan Action to be taken to resolve the problem The Patient’s Medical Record

40 Example of SOAP Entry Problem 1 Pneumonia Subjective “My chest hurts when I take a deep breath” Objective Awake; alert; oriented to time, place, and person; sitting upright in bed with arms leaning over bedside stand; pale, dry skin; respiration 22/min and shallow; pulse 110 beats/min, regular but thready; blood pressure 130/89 (sitting); temperature 101  F; bronchial breath sounds in left bases - posteriorly, occasionally expectorating small amounts of purulent sputum The Patient’s Medical Record

41 Example of SOAP Entry Assessment Pneumonia continues Plan Therapeutic: Assist with coughing and deep breathing at least every 2 hours; postural drainage and percussion every 4 hours; assist with ambulation as per physician orders and patient tolerance. Diagnostic: Continue to monitor lung sounds before and after each treatment. Education: Teach to cough and deep breathe and evaluate return demonstration The Patient’s Medical Record

42 SOAP Form





47 Choose 3 of the National Patient Safety Goals below. And state one thing that the Respiratory Therapist can do to meet the goals that you have chosen.

48 Appropriate Handling of Patient Information Confidentiality is the right of an individual to have personal, identifiable medical information kept private. The Health Insurance Portability and Accountability Act (HIPAA) is a federal mandate that ensures patient confidentiality. HIPAA provides a uniform set of guidelines that apply to all providers and organizations.

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