Information

Technology
 Legal record of care

Confidential, permanent legal document

Chart or admissible in court

Medical
Record Nurses

Legally & ethically responsible for

ensuring confidentiality
 Nurses are legally and ethically
obligated to keep all patient
information confidential.

Nurses are responsible for protecting

records from all unauthorized
readers. Confidentiality
HIPAA requires that disclosure or
requests regarding health information
be limited to the minimum necessary.

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Purposes of the Medical Record

Communication Legal documentation

Reimbursement Education

Research Auditing/monitoring

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The Shift to Electronic
Documentation
• HITECH established provisions to promote the
meaningful use of health information
technology (HIT) to improve the quality and
value of health care
• Experts believe that implementing EHRs across
the health care delivery system will decrease
costs and improve the quality of patient care
• Difference between EHR and EMR
• EHR attributes, components, and advantages

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 Digital version of
patient
data/information
Accurate
documentation f
Longitudinal record of
all healthcare
encounters for a
person/patient Facilitates
What is and interprofessional
communication

EHR? Legal document

Helps to meet
professional,
regulatory & legal
requirements

Helps in QI efforts &

HC research
Privacy, Confidentiality,
and Security Mechanisms
• Electronic documentation has legal risks.
• Use a combination of logical and physical
restrictions to protect information.
• Logical
• Firewalls
• Antivirus
• Spyware software
• Physical security measures include
• placing computers or file servers in
restricted areas or using privacy filters
for computer screens visible to visitors or
others without access.

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Handling and Disposing
of Information
• You must safeguard any information that
is printed from the record or extracted
for report purposes
• De-identify all patient data
• Special considerations for faxing

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 Information Security

Health Insurance Portability & Privacy Rule

Accountability Act [1996]
Use of standard method of maintaining privacy of protected
info
Requires that nurses protect all written & verbal
communication a about clients
Only direct care members can access
Client’s have right to read & obtain copy of their MR
Nurses cannot photocopy any part of MR except for
authorize exchange of documents b/w facilities & providers
EHR must be password-protected
Information Security
Protocols
• Log-off computer before leaving station
• Never share a user ID or password
• Never leave a MR or other printed or
written PHI where visible by others
• Shred any printed or written
information/data after use
Social Media
Precautions
• Know the implications of HIPAA
• Become familiar with facility’s
policies
• DO NOT use or view while in clinical
setting
• DO NOT post info about your facility,
clinical sites/experiences, clients &
other HC staff on social network sites
• DO NOT take pictures that show
clients or their family members
 • Know standards of your organization
• Documentation needs to conform to
standards of the National Committee for
Quality Assurance (NCQA) and TJC to
Standards maintain institutional accreditation and
minimize liability
• Assessment
• Nursing process
• Medical record components

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Guidelines for Quality
Documentation
• Factual
• Accurate & concise
• Complete
• Current
• Organized

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 Elements of Documentation
Factual
Subjective data- document as
“direct quotes” or summarize &
identify as client’s own
statement
Objective data-Descriptive;
includes what nurse sees, hears,
feels & smells. Use no
derogatory words, judgments or
opinions
Accurate & concise Complete & current Organized
Document facts & info Comprehensive & timely Communicate in a logical
precisely Never pre-chart an assessment, sequence
Avoid unnecessary words & intervention or evaluation
irrelevant details
Use only approved symbols &
abbreviations as per TJC &
facility
 Legal Guidelines
• Begin w/date & time
• Record legible entries, non-erasable black ink
• Leave no blank spaces in NN
• Do not use correction fluid, erase, scratch out or blacken out
errors
• Make corrections promptly, following agency policy for error
correction
• Sign all documentation as required by facility, Name & title
• Documentation should reflect
• Assessments, interventions, evaluations, NOT personal
opinions or criticism about client or other HC
professionals’ care
 Flow charts
• show trends in vital signs, blood glucose levels, pain level, and
other frequent assessments
Narrative documentation
• documentation records information as a sequence of events in a
story-like manner

Documentatio Charting by exception

n Formats • uses standardized forms that identify norms and allows selective
documentation of deviations from those norms.
Problem-oriented medical records
• organized by problem or diagnosis and consist of a database,
problem list, care plan, and progress notes
• SOAP, PIE, DAR

EHR
 Guides the nurse through a
Admission nursing history complete assessment to identify
form relevant nursing diagnoses or
problems

Other Flow sheets and graphic records

Common
Record- Patient care summary

Keeping
Forms Standardized care plans or
clinical care guidelines
(CPGs)
Preprinted, established guidelines
used to care for patients who have
similar health problems

Discharge summary forms

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 Reporting Formats
• Change of shift report
• Report given at conclusion of shift
• Hands-off communication [transfer reports
• Transition of care & transfer of patient specific information
• Telephone reports
• Useful when contacting provider
• Telephone or verbal orders/prescription
• Best to avoid these
• Incident reports [occurrence reports]
• Documents an occurrence of an incident or accident
 SBAR
• S-ituation
• B-ackground
• A-ssessment
• R-ecommendation
• Provides a framework for communication b/w members of
the the HC team about a patient’s condition
 Situation
• Clearly and briefly define the situation.
• For example, ‘Mr. Jones has multiple prescriptions of Coumadin in his
home and he is unclear as to which ones he is supposed to take.’
 Background
• Provide clear, relevant background information that relates to the
situation.
• In the prior above, you should consider including the patient’s diagnosis,
the prescribing physicians, and the dates and dosages of the medications.
 Assessment/Recommendation
• Assessment: A statement of your professional conclusion. 
• What do I think the problem is? What is the nurse’s assessment of the situation?
Here the nurse indicates what he or she believes to be the problem based on client
history and current assessment.
• Recommendation: 
• What do you need from this individual? For example, ‘Please clarify which is the
correct dose of Coumadin for Mr. Jones to take and which physician will be
responsible for managing his anticoagulant therapy?’
Problem-Oriented Medical Records
• SUBJECTIVE
• OBJECTIVE
• ASSESSNENT
• NURSING DX BASED ON THE ASSESSMENT
• PLAN
 PIE
• PROBLEM
• INTERVENTION
• EVALUATION
 DAR-FOCUS CHARTING
• DATA
• ACTION
• RESPONSE
 Documentation in the
Home Health Care Setting
• 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.

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 Documentation in the Long-Term Health
Care Setting
• Governmental agencies are instrumental in determining standards and
policies for documentation.
• Documentation in the long-term care setting supports an interprofessional
approach to the assessment and planning process for all patient
• s.

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 Clinical Information Systems
• Computerized provider order entry (CPOE)
• Clinical decision support systems (CDSSs)
• Used to support decision making

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 Nursing Clinical
Information Systems
• Allows nurses to access computerized information at the patient’s bedside
• Enables the nurse to share care plan immediately with the patient
• Can check on laboratory results
• Designs
• Nursing process
• Protocol or critical pathway
• Advantages

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