1. Documentation and Informatics
Chapter 26
Documentation and Informatics
Documentation is anything written or printed on which you rely as a record or proof of patient actions and activities.
Documentation constitutes a fundamental tenet of nursing care.
•The information communicated by nurses regarding their patients’ care reflects the quality of care and accountability for care provided.
•Accreditation agencies such as The Joint Commission specify guidelines for documentation.
•Nurses need to follow basic principles to maintain confidentiality during the transmittal of patient information via verbal, written, or electronic media formats.

2. Confidentiality
Nurses are legally and ethically obligated to keep all patient information confidential.
Nurses are responsible for protecting records from all unauthorized readers.
HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary.
•Breaching confidentiality constitutes an egregious event. Nurses may not discuss a patient’s examination, observation, conversation, diagnosis, or treatment with other patients or staff not involved in the patient’s care.
•All information pertaining to a patient’s health care management that is gathered by examination, observation, conversation, or treatment is confidential.
•Students must be very cognizant of how they collect and transport patient data. They must not have any patient identifiers on their paperwork, including birth date, social security number, room number, or medical record number.
•You can review your patients’ medical records only for information needed to provide safe and effective patient care.
•Access to patient records is limited to individuals involved in the care of the patient.

3. Quick Quiz!
1. Information regarding a patient’s health status may not be released to non–health care team members because
A. Legal and ethical obligations require health care providers to keep information strictly confidential.
B. Regulations require health care institutions to document evidence of physical and emotional well-being.
C. Reimbursement issues related to patient care and procedures may be of concern.
D. Fragmentation of nursing and medical care procedures may be identified.
Answer: A

4. Standards
Current documentation standards require that each patient have an assessment:
Physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs
Nursing documentation standards are set by federal and state regulations, state statutes, standards of care, and accreditation agencies.
The medical record is a legal document that requires information describing the care that is delivered to a patient.
[Make sure to discuss your specific health care facility guidelines.]
•Other standards such as the Health Insurance Portability and Accountability Act (HIPAA) include those directed by state and federal regulatory agencies and are enforced through the Department of Justice and the Centers for Medicare and Medicaid Services.
•Your documentation needs to conform with standards of the National Committee for Quality Assurance (NCQA) and accrediting bodies such as The Joint Commission (TJC) to maintain institutional accreditation and minimize liability.
•TJC standards require that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning.

5. Interdisciplinary Communication Within the Health Care Team
Interdisciplinary communication is essential within the health care team.
Records or chart
Confidential permanent legal document
Reports
Oral, written, or audiotaped exchange of information
Conferences
Team members communicating in a group
•All records contain certain information, such as an informed consent form and patient identification.
•The patient record contains an accurate account of the patient’s health status.
•Any change in a patient’s condition warrants immediate documentation about the event and the action that was taken to keep a record accurate.
•The most common types of reports given by nurses includes change-of-shift reports, telephone reports, transfer reports, and incident reports.
•Team members communicate information through discussions or conferences. For example, a discharge planning conference involves members of all disciplines (e.g., nursing, social work, dietary, medicine, physical therapy) who meet to discuss the patient’s progress toward established discharge goals.

6. Interdisciplinary Communication Within the Health Care Team (cont’d)
Consultations
A professional caregiver giving formal advice to another caregiver
Referrals
Arrangement for services by another care provider
•Consultations are another form of discussion in which one professional caregiver gives formal advice about the care of a patient to another caregiver. For example, a nurse caring for a patient with a chronic wound consults with a wound care specialist.
•Nurses document referrals, consultations, and conferences in a patient’s permanent record to allow all caregivers to plan care accordingly.

7. Purposes of Records Communication Legal documentation Reimbursement
Education
Research
Auditing/monitoring
Communication
Legal documentation
Reimbursement
Education
Research
Auditing/monitoring
•Remember that even if nursing care has been exemplary, “Care not documented is care not provided.”
•Diagnosis-related groups (DRGs) have become the basis for establishing reimbursement for patient care. A medical record audit reviews patient care and at times determines reimbursement.
•The medical record is a financial record that serves as the basis for reimbursement.
•As discussed in Chapter 25, patient education is an important part of nursing practice.
•Research often determines changes made to nursing procedures and protocols. To improve quality of care, researchers collect and study statistical data from patient records.
•The Joint Commission requires hospitals to establish quality improvement programs for conducting objective, ongoing reviews of all patient care. Therefore, nurses perform auditing and monitoring programs.

8. Legal Guidelines for Recording
Correct all errors promptly, using the correct method.
Record all facts; do not enter personal opinions.
Do not leave blank spaces in nurses’ notes.
Write legibly in permanent blank ink.
If an order was questioned, record that clarification was sought.
Chart only for yourself, not for others.
Avoid generalizations.
Begin each entry with the date/time and end with your signature and title.
Keep your computer password secure.
•A nurse’s signature on an entry in a record designates accountability for the contents of that entry.
[Ask the class: What is the correct method for correcting an error in a paper record? Draw a single line through the error, write the word “error” above it, sign your initials, and date it. Then record the note correctly.]
•Accurate record keeping requires objective interpretation of data with precise measurements, correct spelling, and proper use of abbreviations.
[See Table 26-1 on text p. 351 Legal Guidelines for Recording for further discussion.]

9. Guidelines for Quality Documentation and Reporting
Factual
Accurate
Complete
Current
Organized
[What is the difference between subjective and objective data? What are some examples?]
•An objective description is the result of direct observation and measurement. For example, “B/P 80/50, patient diaphoretic, heart rate 102 and regular.”
•The patient’s statements are subjective data. When recording subjective data, document the patient’s exact words within quotation marks whenever possible. For example, the patient states “I feel nervous.”
•Most health care agencies use military time, a 24-hour system that avoids misinterpretation of am and pm times.
[See Table 26-2 on text p. 352 Examples of Criteria for Reporting and Recording for further discussion.]
[Image is Figure 26-1 on text p. 353 Comparison of 24 hours of military time with the hourly positions for civilian time on the clock face.]

10. Case Study
Mrs. Smith is a 93-year-old patient with fractures in her lower spine resulting from severe osteoarthritis that can be treated with surgery. She reports her pain as 10 out of 10.
[Ask the class:
What would be your first step when you hear a patient report pain as 10 out of 10?
What would you record in the chart for Mrs. Smith? Discuss.]

11. Case Study (cont’d)
While completing Mrs. Smith's admission history, you find out that she had a total knee replacement 3 years ago and pain was not well controlled at that time.
Mrs. Smith tells you, “I'm dreading surgery. Last time, I had such pain when I got out of bed.”
[What type of data is provided by Mrs. Smith’s statement? How would you record Mrs. Smith’s statement in your report?]
•Mrs. Smith’s statement provides subjective data. No matter what format you use (narrative, SOAP, PIE, etc.), you would record her statement word-for-word, in quotation marks.

12. Quick Quiz!
2. A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record A. An interpretation of patient behavior. B. Objective data that are observed. C. Lengthy entry using lay terminology. D. Abbreviations familiar to the nurse.
Answer: B

13. Methods of Recording Paper record Electronic health record (EHR)
Episode-oriented
Key information may be lost from one episode of care to the next.
Electronic health record (EHR)
A digital version of a patient’s medical record
Integrates all of a patient’s information in one record
Improves continuity of care
•The key advantages of an electronic health record (HER) for nursing include providing a means to compare ongoing clinical data about a patient with original baseline information and maintaining an ongoing record of a patient’s health education.
•Although the electronic medical record (EMR) contains patient data gathered in a health care setting at a specific time and place and is a part of the EHR, the two terms are frequently used interchangeably.
•Computerized information systems provide information about patients in an organized and easily accessible fashion.

14. Methods of Recording (cont’d)
Narrative
The traditional method
Problem-oriented medical record (POMR)
Database
Problem list
Care plan
Progress notes
•Narrative documentation uses a story-like format. Weaknesses of the narrative format include repetition, length, and disorganization.
•The problem-oriented medical record (POMR) is a method of documentation that is organized according to the patient’s health care problems. Data are organized by problem or diagnosis.
[Describe the type of documentation used by your specific health care facility.]
[See Box 26-1 on text p. 354 Examples of Progress Notes Written in Different Formats for further discussion.]

15. Methods of Recording: Progress Notes
SOAP
Subjective, objective, assessment, plan
SOAPIE
Subjective, objective, assessment, plan, intervention, evaluation
PIE
Problem, intervention, evaluation
Focus charting (DAR)
Data, action, response
The intent of SOAP, SOAPIE, PIE, or DAR charting formats is to organize entries in the progress notes according to the nursing process.
[Make sure to supply examples of the types of documentation used at your health care facility.]

16. Methods of Reporting Source records Charting by exception (CBE)
A separate section for each discipline
Charting by exception (CBE)
Focuses on documenting deviations
Case management plan and critical pathways
Incorporate a multidisciplinary approach to care
Variances
•Source records are separated into nursing, medicine, social work, and respiratory therapy. The advantage is that caregivers can locate each section in which to document entries. The disadvantage is that patients’ problems are distributed across the record, and the record does not show how information is related and care is coordinated to meet patients’ needs.
[See Table 26-3 on text p. 355 Organization of Traditional Source Record for further discussion.]
•Charting by exception (CBE) reduces documentation time and highlights trends or changes. The assumption with this method is that all standards are met unless otherwise documented.
•The case management model of delivering care incorporates an interdisciplinary approach to documenting patient care. Critical pathways are interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established time frame.
•Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame are called variances.
[See Box 26-2 on text p. 355 Example of Variance Documentation for further discussion.]

17. Quick Quiz!
3. A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of A. PIE documentation. B. SOAP documentation. C. Narrative charting. D. Charting by exception.
Answer: C

18. Common Record-Keeping Forms
Admission nursing history form
Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems
Flow sheets and graphic records
Help team members quickly see patient trends over time and decrease time spent on writing narrative notes
Patient care summary or Kardex
A portable “flip-over” file or notebook with patient information
•A nurse completes a nursing history form when a patient is admitted to a nursing unit.
•Flow sheets allow you to quickly and easily enter assessment data about a patient. They use a coding system for data entry.
•Many hospitals now have computerized systems that provide information in the form of a patient care summary that is often printed for each patient during each shift. The summary automatically updates as nurses make decisions, and data (e.g., orders) are entered into the computer.
•In some settings, a Kardex is kept at the nurses’ station. An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day.
[Supply students with these forms. As a class, go over how to fill out the forms. Have students practice before they enter into the hospital for the first time.]

19. Common Record-Keeping Forms (cont’d)
Standardized care plans
Preprinted, established guidelines used to care for patients who have similar health problems
Discharge summary forms
Acuity records
•After completing a nursing assessment, the nurse identifies the standard care plans that are appropriate for the patient and places the plans in the patient’s medical record.
•Discharge documentation includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions.
•Acuity records are not part of a patient’s medical record. They are used for determining the hours of care and the staff required for a given group of patients.
[Supply students with these forms. As a class, go over how to fill out the forms. Have students practice before they enter into the hospital for the first time.]
[See Box 26-3 on text p. 356 Discharge Summary Information for further discussion.]

20. Case Study (cont’d)
Mrs. Smith’s surgery is successful, and she has been discharged by her physician.
What are some key points to consider in providing discharge information?
•Use clear, concise descriptions using words that Mrs. Smith understands.
•Provide step-by-step descriptions of how to perform a procedure (e.g., home medication administration).
•Reinforce explanations with printed instructions.
•Identify precautions to follow when performing self-care or administering medications.
•Review signs and symptoms of complications the patient needs to report to her health care provider.
•Obtain feedback from Mrs. Smith regarding discharge instructions.
•List names and phone numbers of health care providers and community resources for Mrs. Smith to contact.
•Identify any unresolved problems, including plans for follow-up and continuous treatment.
•List actual time of discharge, mode of transportation, and who accompanied Mrs. Smith.
•Document the patient encounter accordingly.
•Example of a sample discharge note: Instructed when to return to the physician for follow-up care, restrictions on how much to lift at home (no more than 10 lbs), and how to best manage her pain at home. Verbalized understanding of the need to be watchful of lifting techniques, as well as the prescribed pain medication action, side effects, and how often she could take the medication. Informed to notify the doctor if the pain does not subside with the prescribed pain medication dosage. Discharged via wheelchair at 1440 accompanied by daughter-in-law.
[See Box 26-3 on text p. 356 Discharge Summary Information for further discussion.]

21. Home Care Documentation
Medicare has specific guidelines for establishing eligibility for home care.
Medicare guidelines for establishing a patient’s home care cost reimbursement serve as the basis for documentation by home care nurses.
Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance.
Nurses need to document all their services for payment.
•Documentation in the home care system is different from that in other areas of nursing.
•Some parts of the record remain in the home with the patient; other information is needed in an office setting. Thus duplication of documentation is often necessary. Agency policies indicate which forms nurses need to leave at their office versus which forms must be taken into the homes.
•Evolving computerized patient records are making it easier for records to be available in multiple locations.

22. Long-Term Health Care Documentation
Governmental agencies are instrumental in determining standards and policies for documentation.
The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation.
The department of health in states governs the frequency of written nursing records.
Long-term care documentation is interdisciplinary and is closely linked with fiscal requirements of outside agencies.
Increasing numbers of older adults and people with disabilities in the United States require care in long-term health care facilities.
•The goal is a system of clinical documentation that improves care for residents and increases reimbursement for that care.

23. Reporting Hand-off report Occurs with transfer of patient care
Provides continuity and individualized care
Reports are quick and efficient.
[What are some examples of things you would want to mention in a hand-off report?]
•For example, if you find that a patient breathes better in a certain position, you relay that information to the next nurse caring for the patient.
[See Table 26-4 on text p. 357 Comparison of Do’s and Don’ts of Hand-Off Reports for a comparison of proper and improper change-of-shift reporting.]
•Rounds allow nurses to perform needed assessments, evaluate patients’ progress, and determine the best interventions for patients’ needs.

24. Reporting (cont’d) Telephone reports and orders
Situation-background-assessment-recommendation (SBAR)
Document every call
Read back
Incident or occurrence reports
Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient
Follow agency policy
•About 60% of the worst type of medical errors, called sentinel events, relate to communication problems that often arise during telephone reports. Use SBAR to standardize telephone communication.
•SBAR stands for situation-background-assessment-recommendation.
•Repeat any prescribed orders back to the physician or health care provider, called “read back,” for verification.
[See Box 26-4 on text p. 358 Guidelines for Telephone and Verbal Orders for guidelines that promote accuracy when receiving telephone orders.]
•Examples of incidents include patient falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of ordered therapies, and circumstances that lead to injury or to risk for patient injury.

25. Quick Quiz!
4. A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to A. Exchange information among health care members. B. Provide information about patients from one unit to another unit. C. Ensure proper care for the patient. D. Aid in the hospital’s quality improvement program.
Answer: D

26. Health Informatics
Application of computer and information science for managing health-related data
Focus on the patient and the process of care
Goal is to enhance the quality and efficiency of care provided.
Driven by the Health Information Technology for Economic and Clinical Health Act (HITECH)
•The government offers incentive payments to health care agencies and providers’ offices that adopt EHRs and use data meaningfully from the EHR to promote safe, high-quality patient care resulting in positive patient outcomes.
•Penalties will be assessed to health care facilities that do not adopt EHRs or show meaningful use of data generated from EHRs.

27. Nursing Informatics
A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
Health care information system (HIS): a group of systems used in a health care organization to support and enhance health care
Consists of one or more
Computerized clinical information systems (CISs)
Administrative information systems
•In health care settings, it is a challenge to easily access data and information about patients. The health care information system (HIS) has been developed to make this process easier.
•An HIS consists of two major types of systems: clinical information systems (CISs) and administrative information systems. Together the two systems operate to make the entry and communication of data and information more efficient.
•For example, a small community hospital uses a nursing information system (NIS); an order entry system; and laboratory, radiology, and pharmacy systems to coordinate its core patient care services.

28. Nursing Informatics (cont’d)
A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
Supports the way that
nurses function and work
Supports and enhances nursing practice through improved access to information and clinical decision-making tools
•Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision making in all roles and settings.
•An expertly designed CIS based on nursing informatics integrates and supports clinical judgments with up-to-date evidence-based practice.
•An effective NIS meets two goals. First, it supports the way that nurses function and work by providing them the flexibility to use the system to view data and collect information, provide patient care, and document a patient’s condition and care provided. Second, it supports and enhances nursing practice through improved access to information and clinical decision-making tools.
•As a nurse, you need to know how to use clinical databases within your institution and apply the information so you can deliver high-quality, appropriate patient care.

29. Nursing Information Systems
Two designs of NISs
Nursing process design
Protocol or critical pathway design
Clinical decision support systems (CDSSs)
Used to support decision making
•NISs have two designs.
•The nursing process design is the most traditional. It organizes documentation within well-established formats such as admission and postoperative assessment problem lists, care plans, discharge planning instructions, and intervention lists or notes.
•The second design model for an NIS is the protocol or critical pathway design. This design offers an interdisciplinary format to manage information.
•A clinical decision support system (CDSS) is based on “rules” and “if-then” statements, linking information and/or producing alerts, warnings, or other information for the user. For example, an effective CDSS notifies health care providers of patient allergies before ordering a medication. This enhances patient safety during the medication ordering process.
[Image is Figure 26-2 on text p. 360 Model of a nursing clinical decision support system (NCDSS). (Courtesy Frank Lyerla.)]

30. Advantages of NISs Increased time to spend with patients
Better access to information
Enhanced quality of documentation
Reduced errors of omission
Reduced hospital costs
Increased nurse job satisfaction
Compliance with accrediting agencies
Common clinical database development
•Successful implementation of a NIS requires preparation, involvement, and commitment of the entire nursing staff.
•More advanced systems incorporate into the software standardized nursing languages such as the North American Nursing Diagnosis Association (NANDA) International nursing diagnoses, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC).

31. Nursing Information Systems (cont’d)
Privacy, confidentiality, and security mechanisms
Legal risks
Handling and disposal of information
Protection of the confidentiality of patients’ health information and the security of computer systems are top priorities that include log-in processes, audit trails, firewalls, data recovery processes, and policies about handling and disposing of data to protect patient information.
•Computerized documentation has legal risks. It is possible for anyone to access a computer station within a health care agency and gain information about almost any patient. Protection of information and computer systems is a top priority.
•Most security mechanisms for information systems use a combination of logical and physical restrictions to protect information and computer systems.
•To protect patient privacy, health care agencies track who accesses patient records and when they access them.
•Printing and faxing information from a patient’s record is a primary source for the unauthorized release of information. All papers containing patient information must be destroyed when no longer needed.
•Nurses may be responsible for erasing computer files from the hard drive that contain calendars, surgery or diagnostic procedure schedules, or other daily records that contain patient information.
•Know and follow the disposal policies for records in the institution where you work.

32. Clinical Information Systems
A hospital information system consists of two major types of information systems: CISs and administrative information systems.
CIS = Monitoring systems, order entry, and laboratory, radiology, and pharmacy systems
Computerized provider order entry (CPOE)
Improves accuracy
Speeds implementation
Improves productivity
Saves money
•Any clinician uses programs available on a clinical information system (CIS).
•A monitoring system includes devices that automatically monitor and record biometric measurements in critical care and specialty areas. These devices electronically send measurements directly to the nursing documentation system.
•Order entry systems allow nurses to order supplies and services from another department.
•Computerized provider order entry (CPOE) is a process by which a health care provider directly enters orders for patient care into the hospital information system.
•The direct entry of orders eliminates issues related to illegible handwriting and transcription errors.
•Orders made through CPOE are integrated within the record and are sent to the appropriate departments (e.g., pharmacy, radiology).