Ppt chapter 09

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 9

Recording and Reporting

Chapter 9

Recording and Reporting


• Medical records are written collections of information about a person’s health, the care provided by health practitioners, and the client’s progress

– Also known as health records or client records

Medical Records Medical Records


QuestionQuestion

•Is the following statement true or false?

Medical records cannot be shared among health care workers.


AnswerAnswer

False.

Medical records are a means to share information among health care workers to ensure client safety and continuity of care.


• Permanent account

• Sharing information

• Quality assurance

• Accreditation

• Reimbursement

• Education and research

• Legal evidence

Uses of Medical RecordsUses of Medical Records


• Joint Commission on Accreditation of Healthcare Organizations (JCAHO) establishes criteria reflecting high standards for institutional health care

• Representatives of JCAHO periodically inspect health care agencies and determine evidence of quality care

• Based on inspection, agencies are accredited

JCAHOJCAHO


• Person’s health information

• Care provided by health practitioners

• The client’s progress

• The plan for care

• Medication administration record

• Laboratory and diagnostic reports

Components of Medical RecordsComponents of Medical Records


Insert Table 9-1

Components of Medical RecordsComponents of Medical Records


Source-Oriented RecordsSource-Oriented Records

• Organized according to source of documented information

• Contain separate forms for physicians, nurses, dietitians, physical therapists to make written entries about their specific activities in relation to client’s care

• This record provides fragmented documentation


Problem-Oriented RecordsProblem-Oriented Records

• Organized according to client’s health problems

• Four major components: data base, problem list, plan of care, progress notes

• Information compiled and arranged to emphasize goal-directed care; promote recording of pertinent information; facilitate communication among health care professionals


Components of Problem-Oriented Records

Components of Problem-Oriented Records


QuestionQuestion


Source-oriented records contain separate forms for all entities to make different entries.


AnswerAnswer

True.

Source-oriented records contain separate forms for physicians, nurses, dietitians, and physical therapists to make written entries about their specific activities in relation to client’s care.


Methods of ChartingMethods of Charting

• Narrative charting

• SOAP charting

• Focus charting

• PIE charting

• Charting by exception

• Computerized charting


QuestionQuestion

•Which of the following charting methods involves writing information about the client and client care in chronologic order?

a. SOAP

b. PIE

c. Narrative

d. Focus


AnswerAnswerc. Narrative charting

Narrative charting involves writing information about the client and client care in chronologic order. SOAP charting involves documenting client data under four essential components. Focus charting is a modified form of SOAP charting. PIE charting is a method of recording the client’s progress under the headings of problem, intervention, and evaluation.


HIPAAHIPAA

• HIPAA legislation protects the rights of U.S. citizens to retain their health insurance

– Requires health care agencies to safeguard written, spoken, and electronic health information

– Health care agencies must obtain authorization from client to release information to family or friends, attorneys, or for other uses


HIPAA (cont’d)HIPAA (cont’d)

• Submits written notice to all clients identifying uses and disclosures of health information

• Obtains client’s signature indicating knowledge of disclosure of information and right to learn who has seen his records

• Limits casual access to identity of client and health information

• Health agencies must ensure protection of electronic data


Beneficial DisclosureBeneficial Disclosure


Workplace ApplicationsWorkplace Applications

• Client names on charts no longer visible to public

• All clipboards must obscure private client data, including name

• Whiteboards cannot link client name with diagnosis, procedure, or treatment

• Computer screens not visible to public; flat screen monitors recommended


Workplace Applications (cont’d)Workplace Applications (cont’d)• Conversations regarding clients must occur

in private places

• Fax machines and medical records must be limited to areas inaccessible to public

• Cover sheet on all faxes; emails warning that confidential information being transmitted

• Light boxes (for x-ray, scan results) must be located in private areas

• Documentation must be kept on all with access to client records


Aspects of DocumentationAspects of Documentation

• The type of information recorded

• The people responsible for charting

• The frequency for making entries on the record

• The type of response given for the information recorded


Nursing DocumentationNursing Documentation


AbbreviationsAbbreviations

• Abbreviations shorten length of documentation and documentation time

• Agencies provide list of approved abbreviations and their meanings

• Use only abbreviations on agency’s approved list

• Use JCAHO “Do Not Use” list to avoid and reduce medical errors


Common AbbreviationsCommon Abbreviations


Documentation TimeDocumentation Time• Traditional time

– Two 12-hour revolutions; identified with hour and minute, followed by a.m. or p.m.

• Military time– Based on 24-hour clock; uses different

four-digit number for each hour and minute of the dayo First two digits indicate hour within 24-

hour periodo Last two digits indicate minutes


Documentation Time (cont’d)Documentation Time (cont’d)


QuestionQuestion


Military time is based on two 12-hour revolutions.


AnswerAnswer

False.

Military time is based on the 24-hour clock while traditional time is based on two 12-hour revolutions.


Charting GuidelinesCharting Guidelines

• Should not be time-consuming to write and read

• Everyone involved in the care of a client should make entries in the same location in the chart

• The nurse should address specific content in charted progress notes


Charting Guidelines (cont’d)Charting Guidelines (cont’d)

• Assessments should be documented on a separate form and give the client’s problems a corresponding number for quick access

• Abnormal assessment findings, or care that deviates from the standard, should also be documented separately

• Client information should be documented electronically

• Information should always be legible


Charting Guidelines (cont’d)Charting Guidelines (cont’d)

• Abbreviations and terms should be consistent with agency-approved lists

• The date of the documentation should be recorded

• The time of the documentation should be recorded


Written Forms of CommunicationWritten Forms of Communication

• Nursing care plan: list of client’s problems, goals, and nursing orders for client care

• Nursing Kardex: quick reference for current information about client and client care

• Checklists: documentation with check mark or initials

• Flow sheets: documentation with sections for recording frequently repeated assessment data


Nursing KardexNursing Kardex

(Refer to Figure 9-8 in the textbook.)


Other Forms of CommunicationOther Forms of Communication

• Change of shift reports

• Client assignments

• Team conferences

• Rounds

• Telephone calls


QuestionQuestion


A nursing Kardex is a documentation with sections for recording frequently repeated assessment data.


AnswerAnswer

False.

Nursing Kardex is a quick reference for current information about client and client care.

Ppt chapter 09

Health & Medicine

Transcript of Ppt chapter 09