IRENE ZEN P. CORPUS , BSN IV
NEAR MISS
RECORDS MANAGEMENT
IMORTANT? - Record Keeping is a vital part of nursing practice. It is essential for the
accurate and effective care of patients. It includes the legal documentation which is
needed for patient care.
Nursing documentation is written evidence verifying that the nurse or healthcare
professional ‘s authorized or moral responsibilities were met in order for nursing care to
be assessed. Well-written, timely, and accurate documentation is an integral part of
nursing practice, whether a nursing student, new nurse, or experienced nurse. It not only
helps make the job easier for you, but helps open up the line of communication between
the healthcare team and the patients.. Healthcare facilities and professionals should
continue working together in order to continually improve their clinical documentation
policies and systems.
1. SENTINEL EVENTS
 A Sentinel Event is defined by The Joint Commission (TJC) as any
unanticipated event in a healthcare setting resulting in death or
serious physical or psychological injury to a patient or patients, not
related to the natural course of the patient's illness.
 Sentinel events specifically include loss of a limb or gross motor
function, and any event for which a recurrence would carry a risk of
a serious adverse outcome. Sentinel events are identified under TJC
accreditation policies to help aid in root cause analysis and to assist
in development of preventative measures.
 The Joint Commission tracks events in a database to ensure events
are adequately analysed and undesirable trends or decreases in
performance are caught early and mitigated.
Sentinel events include "unexpected occurrences involving death or serious
physical or psychological injury, or the risk thereof" and all of the following,
even if the outcome was not death or major permanent loss of function:
– Infant abduction, or discharge to the wrong family.
– Unexpected death of a full-term infant. Severe neonatal jaundice
(bilirubin over 30 milligrams/deciliter).
– Surgery on the wrong individual or wrong body part.
– Instrument or object left in a patient after surgery or another procedure.
– Rape in a continuous care setting.
– Suicide in a continuous care setting, or within 72 hours of discharge.
– Hemolytic transfusion reaction due to blood
– group incompatibilities.
– Radiation therapy to the wrong body region or 25% above the planned
dose
EVENT TYPES-National Accreditation Board for Hospitals & Healthcare Providers (NABH)
1. Surgical events - (wrong body part/ patient/procedure, retained
instrument, death during the procedure, anesthesia related events)
2. Device or Product events - (contaminated drugs and device, unintended
use, breakdown or failure)
3. Patient protection events - (infant discharge, elopement, suicide,
attempted suicide, self-harm, intentional injury, nosocomial infection,
medical gas)
4. Environmental events - (burn, slip, trip, fall, electric shock, use of
restrains and bed rails)
5. Care management events - (hemolytic reaction, maternal death,
medication errors, delay in response)
6. Criminal events - (impersonation, abduction, sexual assault, physical
assault on the grounds of healthcare facility)
2.
 The Occupational Safety and Health Administration (OSHA) near-
miss is a potential hazard or incident in which no property was
damaged, and no personal injury was sustained, but where, given
a slight shift in time or position, damage or injury easily could have
occurred.
 They are a precursor to accidents and are opportunities to identify
hazards and unsafe conditions. It goes without saying that
reporting near misses is a critical tool to create solutions, prevent
accidents and injuries in the future and improve your safety culture
overall.
 Near misses are also referred to as “close calls”, “narrow escapes”
or “miss accidents”
 You are not required to report near misses to OSHA. But they do
recommend recording near miss cases.
 There are two main types of near miss incidents — unsafe condition
near miss and unsafe act near miss.
 Unsafe condition - Circumstances, environment, or state of
equipment which could lead to an accident occurring.
 Unsafe act - Behavior that can potentially lead to damage of
property, personal injury, or death. It’s often related to ignoring
procedures and is signaling the need for new rules.
EX. common near miss scenarios include:
 Non-injury caused due to falling from heights including stairs, Mobile
elevated work platforms (MEWA), rooftops and more
 Slippery conditions that could have led to slips or trips that cause serious
injuries or dislocations.
 Working on machinery without proper Lockout or Tagout procedures
(LOTO).
 Working without proper personal protective equipment PPE like helmets,
gloves, etc.
 Risky or negligent behavior in several scenarios like driving heavy
machinery above the prescribed speed limit.
 Close shave caused due to improper training or maintenance of
machinery.
 Evading the path of a falling object
 Near miss caused due to improper or no signage which could lead
employees to enter otherwise restricted zones without isolations
 A worker slips while carrying a heavy load but manages to catch
themselves before falling.
 A machine malfunctions and causes a loud noise but does not cause any
damage.
 A chemical spill is quickly cleaned up before anyone is exposed to it.
 A worker trips on a loose power cord but does not fall.
 Smoke is seen coming from an electrical outlet, but there is no fire.
 A car almost hits a pedestrian in a crosswalk.
 An elevator door starts to close but opens again when someone steps in
front of it.
 A piece of machinery breaks but does not cause any injuries.
 A gas leak is detected and fixed before it causes any harm.
 A worker slips on a wet floor but does not fall.
 A computer crashes, but no data is lost.
3. ANECDOTAL RECORDS
 A factual record of an observation of a single, specific, significant incident
in the behavior of a student.
 An anecdotal record is an observation that is written like a short story.
They are descriptions of incidents or events that are important to the
person observing. Anecdotal records are short, objective and as accurate
as possible. McFarland (n.d.)
 According to Randall, Anecdotal records are a record of some significant
item of conduct, arecord of an episode in the life of students, a word
picture of the student in action, a wordsnapshot at the moment of the
incident, any narration of events in which may be significantabout his
personality
EX. Examples of anecdotal evidence can range from a friend's review of a new
restaurant to a product review. An anecdote, after all, is a story told to
demonstrate a particular point. Anecdotal evidence can often be used to
support data or develop an argument. Someone might argue that school
uniforms are a great idea and show how they save money. This would be
objective evidence. They may also tell a story about how well uniforms worked
for one particular person. That would be an anecdote that helps their
argument.
The incident recorded should be that is considered to be Significant to the
student’s growth and development of example.
– Simple reports of behavior
– Result of direct observation.
– Accurate and specific
– Gives context of child's behavior
– Records typical or unusual behaviors
4. INCIDENT REPORTS
 According to RNPedia An incident report is a form that filled up in
order to record the details of accidents, patient injury and other
unusual events that occur in a health care facility such as a hospital
or nursing home.
 It is also called an accident report which documents the exact
details of the accident or unusual event while the information is still
fresh in the minds of those who witness the event.
 A remedy for your injuries is essential in order to get justice for the
accident. An incident report will be essential to support your legal
injury case.
 The purposes of an incident report are the following:
– To document the exact detail of an accident or unusual incident that
occurred in a health-care institution.
– To be used in the future when dealing with liability issues stemming
from the incident.
– To protect the nursing staff against unjust accusation.
– To protect and safeguard the client in case of negligence on the part
of the nurse.
– Helps in the evaluation of nursing care to ensure safe care to all
patients.
5. KARDEX
 is a system of communication and organization used in nursing that
helps long term care facilities document patient and resident care
summaries.
 It was created by long term care professionals who saw the need
for all relevant staff members to access important patient and
resident data.
 Traditionally, Kardex is a paper system in which nursing staff write
out information for each resident on a daily basis.
SOURCE: Kraus, A. (2022, April 18). Kardex Nursing in Long Term
care Facilities - Experience care. Experience Care: Long-Term Care
EHR & Financial Software Solutions
6. PATIENT/CHART RECORDS
 A medical chart is a thorough record of a patient’s medical history
and clinical data.
 Information such as demographics, vital signs, diagnoses, surgeries,
medications, treatment plans, allergies, laboratory results,
radiological studies, immunization records is included.
 A good medical chart will paint a clear picture of the patient. It also
provides vital information to allow healthcare practitioners to make
sound decisions based on the information contained in the record.
SOURCE: Gallego, G. (2023, June 2). What is a Medical Chart?
Continuum.
7. 201 FILE
 An employee 201 file, usually contained records/data pertaining to
the employee’s personal information, financial information,
employment contract, duties, job grade, performance, and
employment history for future employment requirements.
 One of the key roles of 201 file management is to help keep track of
the employee records; provide post-employment information &
employment certifications; and the ability to support or document
defenses e.g legal cases filed by an employee at the Depart of Labor
and Employment.
SOURCE: Garfin, J. (n.d.). HUMAN RESOURCE MANAGEMENT: “201”FILES.
www.linkedin.com.
8. ROLES OF NURSE IN RECORDS MANAGEMENT
NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING
 The patient has a right to inspect and copy the record after being
discharged
 Failure to record significant patient information on the medical record
makes a nurse guilty of negligence.
 Medical record must be accurate to provide a sound basis for care
planning.
 Errors in nursing charting must be corrected promptly in a manner that
leaves no doubts about the facts.
 In reporting information about criminal acts obtained during patient
care, the nurse must reveal such information only to the police, because
it is considered a privileged communication.
1. FACT - Information about clients and their care must be functional. A
record should contain descriptive, objective information about what a
nurse sees, hears, feels and smells.
2. ACCURACY - A client record must be reliable. Information must be
accurate so that health team members have confidence in it.
3. COMPLETENESS - The information within a recorded entry or a report
should be complete, containing concise and thorough information about
a client care or any event or happening taking place in the jurisdiction of
manger.
4. CURRENTNESS - Delays in recording or reporting can result in serious
omissions and untimely delays for medical care or action legally, a late
entry in a chart may be interpreted on negligence.
5. ORGANIZATION - The nurse or nurse manager communicates information 4. Responsibility for nurses' notes - The form for nurses' notes which
in a logical format or order. Health team members understand has been established by the hospital should be used by all nurses.
information better when it is given in the order in which it is occurred.
How to improve record keeping
6. CONFIDENTIALITY - Nurses are legally and ethically obligated to keen
– Get into the habit of using factual, consistent, accurate, objective
information about client's illnesses and treatments confidential.
and unambiguous patient information
– Use your senses to record what you did.
7. CONCLUSION -Maintaining good quality records and reports has both
– Ensure there is a reasoned rationale (evidence) for any decision
immediate and long-term benefits for staff.. In the long term it protects
recorded.
individuals and teams from accusations of poor record-keeping, and the
– Ensure notes are accurately dated, timed, and signed, with the
resulting drop in morale. It also ensures that the professional and legal
name printed alongside the entry.
standing of nurses are not undermined by absent or incomplete records,
– Write the notes, where possible, with the involvement and
if they are called to account at a hearing.
understanding of the patient or care taker.
– Errors should be corrected by putting a single line through the
SOURCE Nursing records & reports. (n.d.). PPT.
incorrect statement and signing and dating it.
https://www.slideshare.net/jasleenbrar03/nursing-records-reports
– Follow the SMART model (Specific, Measurable, Achievable,
Realistic and Time-based) or similar when planning care
– Write up notes as soon as possible after an event and, by law, within
9. ROLES OF NURSE MANAGERS IN RECORDS MANAGEMENT 24 hours, making clear any subsequent alterations or additions
 Medical records managers are responsible for maintaining and – Do not include jargon, meaningless phrases (for example 'slept
protecting all patient electronic medical records at a medical well'), offensive subjective statements.
facility. – It must be clear what was originally written and why it was
 They also ensure that all medical information is complete, accurate, changed, therefore correction fluids should not be used.
and restricted for access only to appropriate medical personnel. – The NMC's position on abbreviations is that they should not be used
 Medical records managers serve as gatekeepers who safeguard all (NMC, 2002c).e.g. 'PT' could mean patient, physiotherapist or part
patient medical documentation. They regularly manage, search time; 'BD' could mean twice or brought in dead.
through, and secure patient medical records on behalf of hospitals,
outpatient clinics, medical centers, and any other facility
responsible for patient care.
10. HIPAA
Medical records managers fulfill a wide variety of responsibilities daily, mostly
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
related to the management and protection of all patient medical records.
These individual responsibilities can include: – The Health Insurance Portability and Accountability Act of 1996
(HIPAA) is a federal law that required the creation of national
– Maintaining patient data as records develop.
standards to protect sensitive patient health information from
– Supervising any employees using patient medical data for any
being disclosed without the patient’s consent or knowledge.
reason.
– Managing records databases and ensuring their availability for
Health Insurance Portability and Accountability Act of 1996
continued use by medical staff.
(HIPAA) | CDC. (n.d.).
– Communicating with healthcare personnel who will potentially
https://www.cdc.gov/phlp/publications/topic/hipaa.html#:~:text=
access patient medical documentation.
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– Keeping medical records secure, via online encryption, password
's%20consent%20or%20knowledge
protection, and secure filing practices.
CENTERS FOR DISEASE CONTROL AND PREVENTION
– Retrieving patient medical records whenever approved healthcare
staff need them.
What is the purpose of HIPAA?
– Adding to patient medical files whenever their details need to be
updated or changed.
HIPAA, also known as Public Law 104-191, has two main purposes:
SOURCE: What is a Medical Records Manager Career? (2022, January 6). to provide continuous health insurance coverage for workers who
Western Governors University. lose or change their job and to ultimately reduce the cost of
healthcare by standardizing the electronic transmission of
1. Protection from loss administrative and financial transactions.
The head nurse is responsible for safeguarding the patient's record
from loss or destruction. No individual sheet is separated from the Other goals include combating abuse, fraud and waste in health
complete record unless, as with the doctor's order sheet, it is kept insurance and healthcare delivery, and improving access to long-
in a special place where its safety is guarded. term care services and health insurance.

2. Safeguarding its content

The hospital administration usually has a procedure with which the
head nurse should be familiar for handling legal matter of this kind.
Patient has the right to insist that his record be confidential.

3. Completeness - Compile records with complete identifying data on

each page in the form approved by the hospital. The two parts of
the record for which the nursing service is universally wholly
responsible are the vital sign, graphic sheet and nurses' observation
or nurses' notes.