Chapter 26 Documentation and Informatics Documentation is anything written or printed relating to the client. Documentation constitutes a fundamental tenant of nursing care. The information nurses communicate regarding their clients’ 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 client information via verbal, written, or electronic media formats.

Confidentiality Nurses are legally and ethically obligated to keep client information confidential. Nurses are responsible for protecting records from all unauthorized readers. HIPAA act requires disclosure or requests regarding health information. Breaching confidentiality constitutes an egregious event. Students must be very cognizant of how they collect and transport client data. They must not have any client identifiers on their paperwork, including birth date, social security number, room number, medical record number.

Standards The Joint Commission requires each client have an assessment: Physical, psychosocial, environment, self-care, client education, and discharge planning needs Federal and state regulations, state statutes, standards of care, and accreditation agencies set nursing documentation standards. Make sure to discuss specific health care facility guidelines. The American Nurses Association standard of nursing documentation states that “documentation must be systematic, continuous, accessible, communicated, recorded and readily available to all members of the health care team”. The Joint Commission also expects a multidisciplinary care plan if more than one discipline cares for the hospitalized client.

Multidisciplinary Communication Within the Health Care Team Records or chart: Confidential permanent legal document Reports: Oral, written, audiotaped exchange of information Consultations: A professional caregiver providing formal advice to another caregiver Referrals: Arrangement for services by another care provider The client record contains an accurate account of the client's health status. The most common type of reports given by nurses includes change of shift reports, telephone reports, transfer reports, and incident reports. Remember the most current emphasis on reports for the handing over of patients includes SBAR: situation (briefly state the problem, chief complaints, what is it, when it happened or was reported, and how severe), background (pertinent background information related to the situation such as admitting diagnosis, list of current medications, allergies, IV fluids, most recent vital signs, lab results, and code status), assessment (What is the nurse’s assessment of the situation?), and recommendation (What is it the nurse’s recommendation or what does the nurse want?)

Purposes of Records Communication Legal documentation Financial billing Education Research Auditing/monitoring The client care record is a written account of the client’s needs and progress, individual therapies, content of client care conferences, client education, and discharge planning. The admitting nurse’s history and physical assessment contains biographical data, method of admission, reason for admission, past medical history, current medications, and review of risk factors. The medical progress notes detail the physician’s findings. Table 26-1 gives legal guidelines for recording. Remember, even if nursing care has been exemplary, “care not documented is care not provided.” DRGs have become the basis for establishing reimbursement for client care. A medical record audit reviews client care and at times determines reimbursement. As previously discussed in Chapter 25, client 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 client records. The Joint Commission requires hospitals to establish quality improvement programs for conducting objective, ongoing reviews of all client care. Therefore, nurses perform auditing and monitoring programs.

Guidelines for Quality Documentation and Reporting Factual Accurate Complete Current Organized Proper documentation is the best defense of legal claims associated with nursing care. Documentation must be clearly written and legible, individualized to the client. When charting, you must practice, you must use critical thinking, and you must use the nursing process. Table 26-2 presents examples of criteria for reporting and recording.

Methods of Recording Narrative: The traditional method Problem-Oriented Medical Record (POMR): Database Problem list Nursing care plan Progress note Briefly discuss these different methods of recording. Spend some time on the type of documentation used by your specific health care facility.

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 Make sure to supply examples of the types of documentation used at your health care facility.

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: Incorporates a multidisciplinary approach to care Source records are separated into nursing, medicine, social work, respiratory therapy. The advantage is that care givers can locate each section to document entries. The disadvantage is that the clients’ problems are distributed across the record. CBE reduces documentation time and highlights trends or changes. The assumption with this method is that all standards are met unless otherwise documented. The disadvantage is that this system can pose legal risks if nurses are not disciplined in documenting exceptions. Case management model of delivering care incorporates a multidisciplinary approach to documenting client care. We discussed this in Chapter 2. Critical pathways are multidisciplinary care plans that include client 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.

Common Record-Keeping Forms Admission nursing history form Flow sheets and graphic records Client care summary or Kardex Acuity records Standardized care plans Discharge summary form Supply students with these forms. Help students fill out the forms. Have students practice before they enter into the hospital for the first time.

Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. Nurses need to document all their services for payment. As hospital lengths of stay are shortened, larger numbers of older adults require home care services.

Long-Term Health Care Documentation Governmental agencies are instrumental in determining the 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. The goal is a system of clinical documentation that improves care for residents and increases reimbursement for that care.

Computerized Documentation Software programs allow nurses to enter assessment data. Computers generate nursing care plans and document care. A complete computer-based patient care record (CPCR) is not without legal risks. Confidentiality in the access of records can cause a problem. HIPAA guidelines must be strictly adhered to. Nurses and students alike need orientation to computerized charting.

Reporting Change of shift Telephone reports Verbal or telephone orders Transfer reports Incident reports Table 26-4 presents a comparison of proper and improper change-of-shift reporting. You can role play these reports with students. Remember to impress on students that they cannot take verbal orders or telephone orders. Remember to use SBAR.