information management in nursing · nmt 04209 information management in nursing vii nta level-4,...

September 2013

NMT 04209

InformationManagement in

NursingNTA Level 4 Facilitator’s Guide for Basic

Certificate in Nursing

United Republic of TanzaniaMinistry of Health and Social Welfare

Ministry of Health and Social WelfareDepartment of Human Resources DevelopmentNursing Training Section© Ministry of Health and Social Welfare 2013

NMT 04209 Information Management inNursing

iNTA Level-4, Semester 2

Table of contents

Acronyms ii

Acknowledgement .................................................................................................................................iii

Goals and Objectives of the Training Manual .......................................................................................vi

Overall Goal for training manual .......................................................................................................vi

Objectives for training manual...........................................................................................................vi

Introduction vii

Module Overview .............................................................................................................................vii

Who is the Module For? ...................................................................................................................vii

How is the Module Organized? ........................................................................................................vii

How Should the Module be Used? ...................................................................................................vii

Module Sessions

Session 1: Introduction to Medical Records.....................................................................................1

Session 2: Qualities of Good Medical Report ..................................................................................6

Session 3: Methods of Medical Record Keeping ...........................................................................13

Session 4: Tools Used in Medical Records ....................................................................................19

Session 5: Health Management Information System .....................................................................29

Session 6: Patient Records for Planning and Improving Care .......................................................34

Session 7: Confidentiality with Patient/Client Records .................................................................37

Session 8: Legal Limitations in Managing Patient/Client Records................................................41


iiNTA Level-4, Semester 2

Acronyms

LCD – Liquid Crystal Display

RN – Registered Nurse

EMRs - Electronic Medical Records

MTUHA – Mfumo wa Taarifa za Uendeshaji wa Huduma za Afya

HMIS – Health Management Information System

TD – Terminal – Digit

IPD – In patient department

RCH – Reproductive and child health

DPF – District processing file


iiiNTA Level-4, Semester 2

Acknowledgement

The development of the training manuals for Certificate and Diploma in Nursing (NTA Level4 to 6) has been possible and accomplished through involvement of different stakeholders.The Ministry of Health and Social Welfare (MoHSW) through the Director of HumanResources Development sends sincere gratitude to the stakeholders including thecoordinating team (Department of Nursing and Midwifery Training), TNI, through AIHA andthe WINONA state University for funding the activity.

The MOHSW would like to thank all those involved during the process for their valuablecontribution to the development of these training materials. The ministry of Health would liketo thank the Assistant Director for Nursing Training section Mr. Ndementria Vermand, andMs. Vumilia B.E Mmari (Coordinator for Nursing and Midwifery Training) who tirelesslyled this important process.

Sincere gratitude is expressed to main facilitator: Mr. Golden Masika, Tutorial AssistantUniversity of Dodoma for his tireless efforts and Mr. Nicolaus Ndenzako Programmeconsultant of AMCA inter consultant in guiding participants through the process. Specialthanks go to the team of contributors representing the Health Training Institutions, hospitalsand Universities. Their participation in meetings and workshops and their inputs in thedevelopment of the content for each module have been invaluable. It is the commitment ofthese participants that has made this product possible.

These participants are listed with our gratitude below:

SN Name Title Institution1. Mary S. Matembo Nurse Tutor Korogwe NTC2. Elialilia M. Herman Nurse Tutor MT. Meru Hospital3. Alice Chifunda Nurse Tutor Mbulu NTC4. Lilian Wilfreda Nurse Tutor KCMC5. Aselina Milinga Nurse Tutor KCMC6. Veronica Mahela Nurse Tutor Kahama7. Samwel Mwangoka Nurse Tutor Mbeya SOTM8. Hamza S. Matagira Nurse Tutor Kahama NTC9. Elikana Wallace Nurse Tutor Kolandoto S/Nursing10. Anna Sangito Pallangyo Nurse Tutor Kahama NTC11. David Abincha Nurse Tutor Bukumbi NTC12. Leon S. Mgohamwende Nurse Tutor Tosamaganga NTC13. Crescent D. Ombay Nurse Tutor Haydom S/Nursing14. Kizito B. Tamba Nurse Tutor Ndanda S/N15. Robert E. Moshi Nurse Tutor IMTU college of Nursing16. Oresta Ngahi Nurse Tutor Muhimbili S/N17. Aloyce Ambokile Nurse Tutor Kondoa District Hosp.18. Helma A. Shimbo Nurse Tutor Mwambani NTC19. Elizabeth G. Chezue PNO N Tutor MOHSW HIS & QAS20. Hinju Januarius Obstetrian Dodoma Regional Hosp.21. Manase Nsunza Principal HLT Singida HLTC22. Ezekiel Amata IMC Facilitator Mpwapwa Hosp.


ivNTA Level-4, Semester 2

23. Sostenes D. Ntambuto HLT Tutor SMLS MUHIMBILI24. Anna Sangito Pallanyo N/Tutor Kahama SN25. Naomi Kagya NT Muhimbili26. Aloyce Amboikile Nurse Kondoa27. Golden Masika Lecturer UDOM28. Vumilia B.E. Mmari CD-NT MOHSW29. Upendo kilume Nurse PHN30. Fatuma Iddi Librarian MOHSW31. Shango Nasania Nurse Newala32. George Laisser C/Analyst MOHSW33. Anande Mungure Nurse Tutor Mbulu NTC34. Robert Masano Nurse Tutor Nkinga NTC35. Ambokile Dodoma General Hospital36. Nolasca Mtega Nurse Tutor Tukuyu School of Nursing37. Asteria Ndomba Senior Lecturer CUHAS38. Alfreda Ndunguru39. Elizabeth Chezua MOHSW40. Magwaza Charles41. Ellen Mwandemele42. Robert Mushi IMTU43. Anna Mangula Nurse Tutor Mirembe NTC44. Cesilia Mallya Nurse tutor Newala NTC45. Helma Shimba46. Kapaya Andrew TNMC47. Ntambuto Sostenese48. Joseph Nkungu49. Anastazia Dinho50. Eliaremisa Ayo Nurse Tutor MOHSW51. Grace Mallya Paediatrician RCHS/GBV/VAC-MOHSW52. Dr. Tecla Kohi Senior Lecturer MUHAS53. Dr. Lilian Msele Lecturer MUHAS

Supporting staff:Daniel Muslim Driver, Ministry of Health and Social WelfareFatuma Mohamed Health Librarian, Ministry of Health and Social WelfareMbaruku A. Luga Driver, Morogoro School of Public Health NursingRoselinda RugemaliraAdm. Secretary, Tanzania Nursing & Midwifery CouncilVeronica Semhando Secretary Ministry of Health & Social WelfareGeorge Laizer System Analyst Ministry of Health & Social WelfareSilvanus Ilomo System Analyst Ministry of Health & Social WelfareViolet Mrema Adm. Secretary, Ministry of Health and Social WelfareWalter Ndesanjo System Analyst, Ministry of Health and Social Welfare

Dr. Gozbert MutahyabarwaAg: Director of Human Resource and Development,


vNTA Level-4, Semester 2

Background

In 2007 the Ministry of Health and Social welfare (MOHSW) started the process ofreviewing the nursing curricula at Certificate and diploma level. In 2008 refined anddeveloped NTA Level 4 to 6 Nursing Curricula and in the same year 2008 started theimplementation. The intention was to comply with the National Council for Technical award(NACTE) Qualification framework which offers a climbing ladder for higher skillsopportunity. Advanced Diploma awards are not among the awards of the council and do notconform to NACTE framework. Therefore, institutions offering Advanced Diploma innursing are required to either offer Ordinary Diploma (NTA Level 6) or develop its capacityto offer Bachelor’s Degree (NTA Level 7&8).

These programs have been developed in line with the above consideration aiming atproviding a room for Nurses to continue to a higher learning and achieve advanced skillswhich will enable them to perform duties competently. In addition, WHO advocates forskilled and motivated health workers in producing good health services and increaseperformance of health systems (WHO World Health Report, 2006). Moreover, PrimaryHealth Care Development Program (PHCDP) (2007-15) needs the nation to strengthen andexpand health services at ALL levels. This can only be achieved when the Nation hasadequate, appropriately trained and competent work force who can be deployed in the healthfacilities to facilitate the provisions of quality health care services.

In line with these new curricula, the MOHSW supported tutors by developing qualitystandardized training materials to accompany the implementation of the developed curricula.These training materials will address the foreseen discrepancies in the implementation of thenew curricula. NTA level 8 training materials have been developed after Curricula validationand verification.

This training material has been developed through writers’ workshop (WW) model. Themodel included a series of workshops in which tutors and content experts developed trainingmaterials, guided by facilitators with expertise in instructional design and curriculumdevelopment. The goals of Writer’s Workshop were to develop high-quality, standardizedteaching materials and to build the capacity of tutors to develop these materials. This productis a result of a lengthy collaborative process, with significant input from key stakeholders(NACTE, MOHSW, AIHA and WINONA University) and experts of different organizationsand institutions. The new training package for NTA Level 4-6 includes a Facilitator Guideand Student Manual. There are 28 modules with approximately 520 content sessions


viNTA Level-4, Semester 2

Rationale

The vision and mission of the National Health Policy in Tanzania focuses on establishing ahealth system that is responsive to the needs of the people, and leads to improved healthstatus for all. Skilled and motivated health workers are crucially important for producinggood health through increasing the performance of health systems (WHO, 2006). Withlimited resources (human and non-human resources), the MOHSW supported tutors bydeveloping standardized training materials to accompany the implementation of thedeveloped CBET curricula. These training manuals address the foreseen discrepancies in theimplementation of the new curricula.

Therefore, this training manual for Certificate and Diploma program in Nursing (NTA Levels4-6) aims at providing a room for Nurses to continue achieving skills which will enable themto perform competently. These manuals will establish conducive and sustainable trainingenvironment that will allow students and graduates to perform efficiently at their relevantlevels. Moreover, this will enable them to aspire for attainment of higher knowledge, skillsand attitudes in promoting excellence in nursing practice.

Goals and Objectives of the Training Manual

Overall Goal for training manualThe overall goal of these training manual is to provide high quality, standardized andcompetence-based training materials for Diploma in nursing (NTA level 4 to 6) program.

Objectives for training manual To provide high quality, standardized and competence-based training materials. To provide a guide for tutors to deliver high quality training materials. Enable students to learn more effectively.


viiNTA Level-4, Semester 2

IntroductionModule Overview

This module content has been prepared as a guide for tutors of NTA Level 4 for trainingstudents. The session contents are based on the sub-enabling outcomes of the curriculum ofNTA Level 4 Basic Certificate in Nursing.The module sub-enabling outcome as follows:6.1.1 Organise and manage patients’ medical records6.1.2 Describe different methods of medical records keeping6.1.3 Enumerate and describe various tools used in medical records6.1.4 Practice use of HMIS tools6.2.1 Collect and analyse patient/client records for planning and care improvement6.2.2 Practice confidentiality in managing patients/clients records6.2.3 Explain legal limitations in managing patients/clients records

Who is the Module For?

This module is intended for use primarily by tutors of NTA Level 4 to 6 in nursing schools.The module’ sessions give guidance on the time and activities of the session and provideinformation on how to teach the session to students. The sessions include different activitieswhich focus on increasing students’ knowledge, skills and attitudes.

How is the Module Organized?

The module is divided into 8 sessions; each session is divided into sections. The followingare the sections of each session: Session Title: The name of the session. Learning Tasks – Statements which indicate what the student is expected to learn at the

end of the session. Session Content – All the session contents are divided into steps. Each step has a heading

and an estimated time to teach that step. Also, this section includes instructions for thetutor and activities with their instructions to be done during teaching of the contents.

Key Points – Each session has a step which concludes the session contents near the endof a session. This step summarizes the main points and ideas from the session.

Evaluation – The last section of the session consists of short questions based on thelearning objectives to check the understanding of students.

Handouts are additional information which can be used in the classroom while teachingor later for students’ further learning. Handouts are used to provide extra informationrelated to the session topic that cannot fit into the session time. Handouts can be used bythe participants to study material on their own and to reference after the session.Sometimes, a handout will have questions or an exercise for the participants. The answersto the questions are in the Facilitator Guide Handout, and not in the Student ManualHandout.

How Should the Module be Used?

Students are expected to use the module in the classroom and clinical settings and duringself-study. The contents of the modules are the basis for learning Information Managementin Nursing. Students are therefore advised to learn each session and the relevant handoutsand worksheets during class hours, clinical hours and self-study time. Tutors are there toprovide guidance and to respond to all difficulty encountered by students.


viiiNTA Level-4, Semester 2


1NTA Level-4, Semester 2 Session 1: Introduction to Medical Records

Session 1: Introduction to Medical Records

Total Session Time: 60 Minutes

Prerequisite None

Learning TaskBy the end of this session, students are expected to be able to: Definition of terms Explain purposes of medical records Identify types of Medical records Utilize the qualities of a nurse in management of medical records Apply professional standards in maintaining medical records

Resources Needed Flipcharts, marker pens, masking tape Black / white board and chalk, white board markers, Computer and LCD Overheard projector

SESSION OVERVIEW

Step Time Activity/Method Content

1 05 Minutes PresentationPresentation of Session Title and LeaningTasks

2 05 Minutes Presentation Definition of Terms

3 15 Minutes Presentation Purposes of Medical Records

4 05 Minutes Presentation Types of Medical Records

5 15 MinutesPresentation,

Group DiscussionQualities of a Nurse in Management ofMedical Records

6 05 MinutesPresentation Professional Standards in Relation to Medical

Records

7 05 Minutes Presentation Key Points

8 05 Minutes Presentation Evaluation



SESSION CONTENT

Step 1: Presentation of Session Title and Leaning Tasks (5 minutes)

READ or ASK students to read the learning tasks and clarify

ASK students if they have any question before proceeding

Step 2: Definition of Terms (5 minutes)

Medical record is storage of the knowledge and information concerning a particularpatient.

The Patient Record is a written account of the patient’s illness and response to treatmentand care

The patient record is permanent and can be retrieved many years later if the patient’shealth history is needed.

Documentation is anything written or printed that is relied on as a record or proof forauthorized persons.

Documentation within a client medical record is a vital aspect of nursing practice. The common term for documentation is “charting.” The chart is the client’s health record

Step 3: Purposes of Medical Records (15 minutes)

Communicationo Clearly documented information of the patient’s record communicates the plans of

care and the patient’s progress to all members of the healthcare team.o Team members who interact with the patient at different times and in different ways

get a clear picture of what took place in their absence.o This communication ensures continuity of care and provides essential data for

revision or continuation of care. Assessment

o Nurses and other team members gather assessment data from the patient’s history andinitial assessment and comparing these data with additional subjective and objectivedata/information that has been obtained, current health status and progress towardsgoals can be determined.

o Progressive assessments of lung sounds, for example might alert the nurse to adeveloping infection or indicate that fluids are accumulating in the postoperativepatient.

Care planningo Formulation of a plan of care flows from assessment data in the patient’s record.o An individualized nursing plan of care is essential for each patient and becomes part

of the permanent patient record.o Consider all data on the patient record when developing nursing diagnoses, goals,

outcome criteria, interventions and evaluation criteria for that patient.o An individualized nursing plan of care is essential for each client and becomes part of

the permanent patient record. Quality assurance



o An audit is a review of record.o Audits of patient records serve a dual purpose: quality assurance and reimbursement.o Auditing is done for quality assurance by randomly selecting records to see if certain

standards of care have been met and documented.o If deficiencies are detected educational programs can be designed to improve

outcomes in those areas. Reimbursement

o Documentation of patient care often provides the basis for decision regarding care tobe provided and subsequent reimbursement to the agency.

o Workers’ compensation and insurance companies usually require specific criteria tobe met to cover health-related expenses.

Legal documentationo The patient record serves as a legal document of the patient’s health status and care

received.o It may be used in court to prove or disprove injuries a patient incurred unintentionally

or to implicate or absolve a healthcare professional for improper care. Research

o Nursing and healthcare research is carried out by studying patient record.o The record may be studied by researchers who are hoping to learn from the study of

similar cases how best to recognize or treat other patients’ health problems.o For example, a nurse epidemiologist may review the records of patients who had

tuberculosis to determine patterns of disease in the community.o This information might be used in designing culturally appropriate education and

planning more effective primary prevention strategies. Educational purposes

o Members of the healthcare team, including students of nursing, medicine, and otherdisciplines, use the patient record as an educational tool.

o It contains valuable information about signs and symptoms of disease, diagnostictests, treatment modalities and patient responses to the disease and treatment.

o A nursing student, for example, may read the record of patient experiencing a stroketo learn the signs and symptoms that the patient initially experienced, the effects ofmedication given to minimize brain injury and the contribution of physical therapy tohelp the patient reach rehabilitation goals.

Step 4: Types of Medical Records (5 minutes)

Source-oriented patient recordIt is a type of record in which each healthcare team keeps data on its own separate form.Sections of the record are designed for nurses, physicians, and laboratory and x-raypersonnel.

Problem-oriented patient recordsIs a type of a record which is organized around a patient’s problems rather than aroundsources of information

All healthcare professionals record on the same forms.



Step 5: Qualities of a Nurse Pertaining to Medical Records (15 minutes)

Activity Small Group Discussion: (15 minutes)

DIVIDE Students into small manageable groups.

TELL: The student read the following situation and identify the possible consequences asinstructed below

‘Jane is a newly qualified nurse who is working in Care and Treatment Centre in of theDistrict hospitals. One of her role to conduct counseling to clients. She received a client forcounseling ‘after counseling session the client agrees to be tested for HIV. The test revealedthat the client was positive for human deficiency virus (HIV). Jane communicated the resultsto the client. However she also exposed the results to the relatives and neighbors withoutconsent from the client’.

TELL student to read the above situations that pertain to the qualities of a nurse. Review the qualities of nurse What type of the quality of a nurse has been violated

SUMMARIZE by reviewing the qualities of a nurse and continuing with following content

Step 6: Professional Standards in Relation to Medical Records (5 minutes)

To meet professional standards in medical records documentation and confidentiality isvital.

Documentation serves as permanent record of patient information and care. The patient record provides information during the present visit or admission and may be

consulted in the future to review the patient’s history or for educational, research andlegal purposes.

Nurses are responsible for accurate, complete and timely documentation and reporting. Confidentiality: Patients expect that information about them will be shared only with

those who need to know and who will be contributing to their care.

Step 7: Key Points (5 minutes)

Medical record is storage of the knowledge and information concerning a particularpatient.

Client record are kept for a number of purposes, including communication, planning,patient care, auditing, health agencies research, education, reimbursement, legaldocumentation and health care analysis.

In source-oriented clinical records, each health care professional group provides its ownrecord. Recording is orientated around the source of information.

In problem-oriented clinical records, recording is organized around patient problems



Step 8: Evaluation (5 minutes)

What are the seven (7) primary purposes of the medical health records Mention two types of Medical record. Mention two important professional standards in managing health records.

ASK students if they have any comments or need clarification on any points

References

Craven, F. R. & Constance J. H. (2000). Fundamentals of Nursing. (3rd ed). Philadelphia,USA: Lippincott Williams & Wilkins

Efoghor,J. E. (2010). Qualities of a Professional Nurse from http://ezinearticles.com/?20-Qualities-of-a-Professional-Nurse&id=5239489. Retrieved on January 5, 2011.

Hornby, A. S. (1993). Oxford Advanced Learner’s Dictionary. (4th ed). UK: OxfordUniversity Press.

Kozier, B., Glenora E.R.B., Audrey, B., et al (2004). Fundamentals of Nursing. (7th ed).New Jersey, USA: Pearson Education Inc.

MHSW. (2008). Basic Nursing Procedures. 3rd ed. Dar Es-Salaam Tanzania: Ministry ofHealth and Social Welfare

Potter, P. A & Anne Griffin Perry. (2005). Fundamentals of Nursing (. 6th ). USA: MosbyInc.

Taylor C, Carol L, & Priscilla LeMone, (1993). Fundamentals of Nursing, (2nd ed).Philadelphia. USA: Lippincott Company


6NTA Level-4, Semester 2 Session 2: Qualities of Good Medical Report

Session 2: Qualities of Good Medical Report


Prerequisite None

Learning TasksBy the end of this session, students are expected to be able to: Identify guidelines for quality documentation and reporting medical records Evaluate patient medical record Formulate documentation according legal and professional guidelines Translate patient medical records and develop a nursing plan

Resources Needed: Flipcharts, marker pens, masking tape Black / white board and chalk, white board markers, Computer and LCD Overheard projector

SESSION OVERVIEW


1 05 Minutes PresentationPresentation of Session Title and LearningTasks

2 20 MinutesPresentation Guidelines for Quality Documentation and

Reporting Medical Records

3 15 Minutes Presentation Evaluation of Patient Medical Record

4 25 MinutesPresentation Documentation According to Legal and

Professional Guidelines


Group DiscussionTranslation of Patient Medical Records andDevelopment of a Nursing Plan





SESSION CONTENT

Step 1: Presentation Of Session Title and Learning Tasks (5 minutes)

READ or ASK students to read the related tasks and clarify

ASK students if they have any question before continuing

Step 2: Guidelines for Quality Documentation and Reporting MedicalRecords (20 minutes)

Quality documentation Accuracy

o A client’s name and identifying information be stamped or written on each page of theclinical record.

o Before making any entry, check that it is the correct chart.o Don’t identify charts by room number only; check the patient’s name.o Special care is needed when caring for patients with same last name.o Notation on records must be accurate and correct.o Accurate notations consist of facts or observations rather than opinions or

interpretations.o It is more accurate, for example to write that the “patient refused” (fact) than to write

that the patient “was uncooperative” (opinion); to write that the patient “was crying”(observation) is preferable to note than the patient “was depressed” (interpretation).

o When describing something, avoid words such as large, good, or normal, which beinterpreted differently?

o For example, chart specific data such as “2 cm x 3 cm bruise” rather than “largebruise”.

o When a recording mistake is made, draw a line through it and write the wordsmistaken entry above or next to the original entry with your initials or name.

o Do not erase, blot out, or use correction fluid.o When using computerized charting, the nurse needs to be aware of the agency’s

policy and process for correcting documentation mistake.o Write on every line but never between lines

Sequenceo Document events in the order in which they occur; for example record assessment,

then the nursing interventions, and then the patient’s responseso Update or delete problems as needed

Appropriatenesso Record only information that pertains to the patient health problems and care.o Any other personal information that the patient conveys is inappropriate for the

record.o Recording irrelevant information may be considered an invasion of the patient’s

privacy.o For example a patient’s disclosure that he was addicted to heroin 20 years ago would

not be recorded on the patient’s medical record unless it had a direct bearing on thepatient’s health problem.

Completenesso Not all data that a nurse obtains a patient can be recorded.



o Nurses’ notes need to reflect the nursing process.o Record all assessments, dependent and interdependent nursing interventions, patient

problems, patient comments and responses to interventions and tests, progress towardgoals, and communication with other members of the health team.

o Include care that was omitted because of the patient’s condition or refusal oftreatment.

o Document what was omitted, why it was omitted, and who was notified. Organization

o The nurse communicates information in a logical order.o For example, an organized note describes the client’s pain, nurses’ assessment and

interventions, and client’s response.o In writing notes on complex situation in an organized manner, the nurse need to thing

about the situation and make notes of what is to be included before beginning writingthe permanent legal

Legibilityo Writing must be clear and easily read by others.o Legibility is especially important when recording numbers and medical terms. For

example, a pulse rate of 164 may look similar to 104, but has more seriousimplications.

o The term dysphasia (difficult speaking) may be mistaken for dysphasia (difficulty inswallowing)

Step 3: Evaluation of Patient Medical Record (15 minutes)

Good medical records should be:-o Economical – and written within the hospital budget to maintain it. Before introducing new documents the initial cost, and continual annual

expenditure, should be looked at carefully and weighed against benefits whichmay accrue in better patient care.

o Concise, but clear – and not too bulky for easy filing Smaller cards are quite adequate for the fairly brief notes required in primary and

secondary care where doctors are generally hard-pressed for time, with manypatients waiting for their attention every day.

Clinicians should be encouraged to write concise, clear notes on the patients’complaints, with their significant positive findings and important negative ones.

o Easily retrievable Retrievability means the ability to find old records when the patient comes again. The patient’s records should be filed in such a way that old records can be quickly

traced, and thus promote satisfactory continuity of care. Any system, where the stores records take up a lot of space are difficult to file

tidily, or where the index number cannot be seen until the file is pulled out fromthe shelf – all these make retrieval difficult.

Every patient has a right to continuity of care – for life, if possible. Retrievability of records, by one means or another is therefore essential



Step 4: Document According to Legal and Professional Guidelines (25minutes)

A clinical record, also called a chart or patient record is a formal, legal document thatprovides evidence of a patient’s care.

Although health organizations use different systems and forms for documentation, allpatient records have similar information

o The patient record is a legal document and may be used to provide evidence in courttherefore many factors are considered when documenting

o Healthcare personnel must maintain confidentiality as well as meet legal standards inthe process of documentation.

Guidelines for Legal Documentation Document what you see

o Describe exactly what you observe, and document what you see.o Describe your assessment objectively; do not give your opinions or interpretations.o For example, when you observe bleeding, indicate how much blood there is; its

colour; whether it is gushing, oozing, or running; and its source.o When you are describing a client’s response, describe the client’s activity, not what

you think it means.o For example, “client crying and rocking back and forth in chair” is an objective and

descriptive statement.o Identify the client’s reaction to you actions, whether is to medication given, client

teaching, or nursing interventions.o Record the client’s response, as well as the time, dosage, description and any other

adverse effects. Be Specific

o Avoid ambiguous statements and generalizations.o For example, “had an uncomfortable night” does not say anything specific, where as

“client was up 10 times with diarrhea during the night” tells why the client had anuncomfortable night and why sleep was interrupted.

Use direct Quoteso Directly quote the client, and differentiate the client’s words from your observations.

Enclose the client’s statements in quotation marks so others will know exactly whatthe client said. For example:

o Mrs. David said “I have a throbbing pain in my head.”o Note that this documented statement is specific, describing how the client interprets

the pain.o Do not chart hearsay, such as what someone else has told you about the client, unless

you quote it. For example:o Mrs. Charles’s husband said, “My wife does not like the food here.”

Be Prompto Document immediately after giving all care, medications, and treatments with the

date, and time for each entry recorded.o If you forget to document a pertinent fact and add it after you have entered other

documentation in the health record, you must identify your entry as a “late entry.”



Be clear and Consistento Correct spelling, punctuation, and sentence structure are essential. “Bathed in

wheelchair in hall” is not clear statement. “Client has had a bath given by the nurseand is now sitting in a wheelchair in the hallway” is clear and accurate.

o On manual records, write or print neatly in black/blue ink.o Make sure the record is continuous and legible.o Use the format specified by that particular institution. Indicate the date and time of

each entry.o Use only commonly accepted abbreviations, symbols and terms that are specified by

the agency. Many abbreviations are standard and used universally; others are usedonly in certain geographic areas.

o Sign the health record with your first initial, last name and the title; (e.g. G. Emanuel,R.N).

o In computerized charting, each nurse may have his or her own code. Nurses need tofollow agency’s policy about how to sign their names.

o Do not leave vacant lines in the health record.o Using every line maintains the chronology of charting.o If a vacant line is left between entries, draw a line through it, to indicate that the

document is chronologico Always replace the health record where it belongs.o Do not remove from the nursing station unless you have consulted the charge nurse or

team leader. Record all Relevant Information

o Read the clinicians notes. If you have any questions or concerns ask the clinician.o Document all communications with other members of the health teamo Follow policies and procedures of other departments to protect the client. For

example, the care plan notes that side rails must be put after 10 pm, document thatyou have followed this guideline.

o If you do not carry this order, you must state the reason in the documentation. Respect Confidentiality

o Confidentiality means that conversations with clients and nursing observations andassessments are shared only with the appropriate caregivers in the proper setting

o What you record and show to the client and other health professionals is never to beshared with anyone else.

o Remember to maintain confidentiality during telephone conversations, taking carethat a bystander does not hear confidential information.

o Do not allow clients to see the computer screen.o Be careful to maintain client confidentiality in the home care setting as well, when

family or friends are present and eager to learn about your client.o Keep in mind that you may be liable in court for “breach of confidentiality.”

Record Documentation erroro If errors occur, you should not change or delete errors made in the patient’s notes.o A notation about the error must be made.o Draw a single line through the error and write the word “error” and your initials above

it. (Your original note must be readable).



o

Step 5: Translation of Patient Medical Records and Development of aNursing Plan (45 minutes)

Activity: Small Group Activity (45 minutes)

DIVIDE students into small manageable groups.

ASSIGN groups to go the pediatric ward, where there is a child of 6 months old admittedwith cerebral malaria. The assessment revealed the following:- Temperature 39.5˚ C Apex beat 140/minute, Respiration 70 The child is jaundiced, sunken eyes and elastic skin on touch.

ASK students to translate the patient’s record and develop a plan of care to this child in theirgroups for 15 minutes.

ASK students to present the developed plan of care for discussion plenary for 3 minutes pergroup.

SUMMARIZE the responses from groups leading to correct answered and insist that;through translation, the patient’s problems and needs can be identified that will lead settingnursing interventions. Continue with the following content


Client records are legal documents and are admissible as evidence in a court. Confidentiality means a client’s right to privacy that healthcare personnel safeguard in

both documentation and reporting Record entries should be brief, accurate, legible, chronologic, made on consecutive lines,

and appropriately signed. Record entries are made after nursing assessments, interventions and evaluations Because the record is a legal document, nurses sign their legal names according to agency

policy and use standard terms and abbreviations. Reports about clients need to be concise and pertinent and must include significant

changes the client’s condition and therapy.


What is Confidentiality? List at least six guidelines for effective documentations What are the six (6) qualities of documentation


References Craven, F. R. & Constance J. H. (2000). Fundamentals of Nursing. (3rd ed). Philadelphia,

USA: Lippincott Williams & Wilkins.



Davis N, & Lacour N., (2002). Introduction to Health Information Technology. USA:W.B. Saunders Company

Donabebdian, A. (2003). An Introduction to Quality Assurance to Health Care, London:Oxford University Press

Efoghor,J. E. (2010). Qualities of a Professional Nurse from http://ezinearticles.com/?20-Qualities-of-a-Professional-Nurse&id=5239489. Retrieved January on 5, 2011.

Hornby, A. S. (1993). Oxford Advanced Learner’s Dictionary (4th ed). UK: OxfordUniversity Press.

Kozier, B., Glenora E.R.B., Audrey Berman., et al. (2004). Fundamentals of Nursing. (7th

ed). New Jersey USA: Pearson Education Inc. MOHSW. (2008). Basic Nursing Procedures. (3rd ed). Dar Es-Salaam Tanzania: Ministry

of Health and Social Welfare Nell Di Lima, S., Johns, L., Johns & Liebler, J. G., (1998) A Practical Introduction to

Health Information Management. Maryland, USA: Aspen Publishers Gaithersburg Potter, P. A & Anne Griffin P. (2005). Fundamentals of Nursing (. 6th ed). USA: Mosby

Inc. Rosdahl, C. B. (1999). Textbook of Nursing. ( 7th ed). Philadelphia, USA: Lippincott

Williams & Wilkins. Taylor C, Carol L, & Priscilla L.M. (1993). Fundamentals of Nursing, (2nded).

Philadelphia. USA: Lippincott Company


13NTA Level-4, Semester 2 Session 3: Methods of Medical Record Keeping

Session 3: Methods of Medical Record Keeping


Prerequisite None

Learning TaskBy the end of this session, students are expected to be able to: Differentiate between manual and electronic methods of record keeping Explain influencing factors in choosing a method in record keeping List pros and cons of both manual and electronic record keeping methods

Resources Needed: Flipcharts, marker pens, masking tape Black / white board and chalk, white board markers, Projector (LCD) Laptop computer

SESSION OVERVIEW


1 05 Minutes PresentationPresentation of Session Titles and LearningTasks

2 20 Minutes Presentation,Manual and Electronic Methods of RecordKeeping

3 10 MinutesPresentation Influencing Factors in Choosing a Method in

Record Keeping


BuzzPros and Cons of both Manual and ElectronicRecord Keeping Methods



SESSION CONTENT

Step 1: Presentation of Session Title and Learning Tasks (5 minutes)





Step 2: Methods of Records Keeping (20 minutes)

There are two types of Medical records keepingo Manual record keepingo Electronic record keeping

The Differences between Manual and Electronic Methods of Records Keeping Manual record keeping

o It tells the story of the patient relationship with the healthcare facilityo A notebook or binder kept in a central location such as nurses’ station or main

administrative officeso Some of the forms may be kept in patients record at his or her bedside for

convenienceo The manual health record, documents assessment, data, care plans treatment outcome

and patient’s daily progress.o Care providers enter information by hand in ink at frequent intervals.

Electronic record keepingo The electronic medical record is a complex computer network that uses a medical

information system for storing, processing and transmitting patient data.o This network is a series of terminal attached to central computer that handle the actual

storing and processing of informationo The terminal consisting of a monitor and keyboards is located in every nursing care

unit and offices.o Other systems may use laptop computer and the patient’s roomo It also record assessment data, plans and nursing information about the patient’s

conditions and response.

Step 3: Factors in Choosing a Method in Record Keeping (10 minutes)

The simplicity of the method for keeping record The safety of the method in record keeping Cost effective of the method in record keeping Knowledge and skills of the health providers Accessibility of the methods Amount of information to be stored

Step 4: Pros and Cons of Manual and Electronic Record Keeping Methods(45 minutes)



Activity: Buzzing (15 minutes)

ASK students to buzz in pairs on ‘pros and cons of manual and electronic record keepingmethod for 5 five minutes

ALLOW few pairs to share their responses

WRITE their responses on the board/flip chart paper

SUMMARIZE the responses and continue with the following content.Pros of Electronic Medical Records (EMRs) EMRs reduce errors

o The use of EMR supposedly reduces errors in medical records.o There is no doubt that handwritten records are subject to lots of human errors due to

misspelling, illegibility, and differing terminologies.o With the use of EMRs, standardization of patient health records may eventually

become achievable. EMRs keep records safe

o Paper records can be easily lost.o We have heard how fires, floods and other natural catastrophes destroy physical

records of many years, data which are lost forever.o Digital records can be stored virtually forever and can be kept long after the physical

records are gone. EMRs help keep records of health information for long time

o For example Inoculations, previous illnesses and medications EMRs make health care cost-efficient

o EMRs consolidate all data in one place.o Previously, paper-based records were located in different places and getting access to

all of them takes a lot of time and money.o In some cases, medical tests that have already been done were repeated all over again,

incurring unnecessary costs to the patients and the health care system. EMRs facilitate coordination between health professionals

o The coordination between primary care providers and the hospital care of patients hasalways been problematic.

o For example in a systematic review, Kripalani et al., evaluated the communicationtransfer between primary care physicians and hospital-based physicians and foundsignificant deficits in medical information exchange.

o They reported that discharge reports from hospitals frequently do not get to thegeneral practitioners in time, resulting in decreased quality of care afterhospitalization.

o Furthermore, the reports tended to be inaccurate and incomplete, often lackingrelevant data about tests and new medications.

o The review recommended the use of EMRs to resolve these issues and facilitate thecontinuity of care before, during and after hospitalization.

EMRs translate into better treatment for patientso Efficiency and speed of diagnosis translates into better health care service for patients.o Similarly correct and timely information can significantly increase the quality of

health care services rendered to patients.o An example of one asthma center’s experience with EMR is that after implementation



of EMR, the number of children who were hospitalized with an asthma exacerbationand received an asthma action upon discharge increased to 58%.

o Prior to the EMR system, only 4% received an asthma action plan before discharge. EMRs can save peoples’ lives

o In many cases, EMRs can save peoples’ lives under unusual circumstances.o Researchers at the Regenstrief Institute in Indiana have been working on EMRs for

years which can be used in disease surveillance during epidemics and bioterrorism.



Cons of Electronic and Manual records Electronic Medical Records (EMR)

o EMRs threaten our privacy Not many people are comfortable about having their entire medical history

recorded and digitized for almost just anybody to see – in other words, incursioninto people’s privacy.

o EMRs can lead to loss of human touch in health care In the process of digitalization, the interpersonal aspect in health care may be lost. In handwritten hospital charts, doctors and other health care practitioners may

write what they think and they feel based on their personal observations in theirvery own words.

EMR is simply about ticking off boxes and crossing out things in electronic forms. The doctors are forced to think in categories and can seldom express a personal

opinion on an individual case. Because of the lack of flexibility of many electronic reporting systems, cases of

misclassification of patients and their conditions have been reported.o EMRs are not that efficient Despite efforts in digitalization and standardization, EMRs are actually far from

being standardized and not as efficient as it is purported to be. It often happens that one clinic’s EMR system is not compatible with that of a

general practitioner or another clinic’s system, thus belying the claim of addedefficiency.

In addition, not all users of EMRs are satisfied with the current state of the art.Although the objective is mainly efficiency and healthcare quality, one studyshowed that nurses in the Netherlands are not completely satisfied with their EMRimplemented in 2006-2007. Furthermore, there was no marked improvement intime efficiency.

o EMRs are not safe and secure Very few people are confident about the data protection and security of electronic

data such as those stored in EMRs. Many people are not convinced that their data are safe from those who would

want to misuse it.o EMRs can be difficult to establish and maintain in developing countries. For

example:- Factors like the population demographics, location, of the care centre and the

availability of resources such as electricity and internet may affect theimplementation of EMR.

Some physicians continue to resist the new technology, as they prefer the standardmethod of record keeping.

Manual Medical Recordso Manual records can be easily lost Fires, floods and other natural catastrophes destroy physical records of many

years, data which are lost forever.o Manual based medical records:- Have proven to be inefficient and are continuously failing to meet the care

provider’s needs. It is time-consuming. The communication between care providers is extremely difficult especially in

developing countries. If paper-filed medical record is needed to be seen by a different care provider it

would be hand-delivered to the responsible person (e.g. Health Officer).




Medical records can be kept manually or electronically. Electronic medical record is a complex computer network that uses a medical information

system for storing, processing and transmitting patient data. Both manual and electronic records have pros and cons. Pros of electronic record keeping include it reduces errors, keep record safe, helps to keep

the records for a long time; it is cost-effective and facilitates coordination between healthprofessionals.

The cons of Electronic record keeping include: it threatens the patient’s privacy, leads toloss of human touch in health care and is not safe and secure.

The cons of Manual record keeping are records can easily be lost, have proven to beinefficient and are continuously failing to meet the care provider’s needs and it is time-consuming.


Explain two types of record keeping Compare and contrast the manual and electronic methods of records keeping Enumerate the advantages and disadvantages of both manual and electronic record

keeping methods.


References

Craven, F. R. & Constance J. H. (2000). Fundamentals of Nursing. (3rd ed). Philadelphia,USA: Lippincott Williams & Wilkins.

Efoghor,J. E. (2010). Qualities of a Professional Nurse from http://ezinearticles.com/?20-Qualities-of-a-Professional-Nurse&id=5239489. Retrieved on January 5, 2011.

Hornby, A. S. (1993). Oxford Advanced Learner’s Dictionary (4th ed). UK OxfordUniversity Press.

Kozier, B., Glenora E.R.B., Audrey Berman, & Shirlee S. (2004). Fundamentals ofNursing. (7th ed). New Jersey, USA: Pearson Education Inc.

MOHSW. (2008). Basic Nursing Procedures. (3rd ed). Dar Es-Salaam, Tanzania:Ministry of Health and Social Welfare

Potter, P. A & Anne Griffin Perry. (2005). Fundamentals of Nursing (. 6th ed). USA:Mosby Inc.

Taylor C, Carol L, & Priscilla LeMone, (1993). Fundamentals of Nursing, (2nd ed).Philadelphia. USA: Lippincott Company


19NTA Level-4, Semester 2 Session 4: Tools Used in Medical Records

Session 4: Tools Used in Medical Records


Prerequisite None

Learning TasksBy the end of this session, students are expected to be able to: Differentiate tools used in medical records Practice filling of various tools used in medical records Retrieve information using appropriate medical record tools

Resources Needed Flipcharts, marker pens, masking tape Black / white board and chalk, white board markers, Computer and LCD Overheard projector MTUHA Tools – Books and Various Forms

SESSION OVERVIEW



2 20 Minutes Presentation Differentiating Tools Used in Medical Records


Group DiscussionPractice Filling of Various Tools Used inMedical Records


Group DiscussionRetrieving Information Using AppropriateMedical Record Tools



SESSION CONTENT






Step 2: Tools Used in Medical Record (20 minutes)

MTUHA Tools HMIS is a system designed to collect facility based health and health related data,

compile, store and retrieve for data analysis to produce report which in turn informservice providers, health managers, decision makers/policy makers and the public tomake informed decision on health planning, monitoring and evaluation.o The Health Management Information System (HMIS) was introduced throughout the

country between 1994 and 1997.o HMIS is a decentralized, integrated and functional information system that covers all

health programs and health care services.o HMIS in Tanzania is called in Kiswahili MTUHA.o MTUHA is the acronym for ‘Mfumo wa Taarifa za Uendeshaji wa Huduma za Afya’.

Flow Sheetso A Flow sheet enables nurses to record nursing data quickly and concisely and

provides an easy-to-read record of the patient’s condition over time.o Flow sheets record routine nursing intervention.o They are used to record measurements or observations made at frequent intervals as

follows:- The graphic sheet This is used to record patient measurements and observations that are made every

shift or 4 to 5 times per day. Information may include:-The patient blood pressure, temperature, pulse and

respiration, Height and weight and fluid Balance Record All routes of fluid intake and routes of fluid loss or output are measured and

recorded on this form. Medication Administration Record

o Medication flow sheets usually designated areas for the data of the medication order,the expiration data, the medication name and dose, the frequency of administrationand route, and the nurses/doctors signature.

o Some records also include a place to document the patient’s allergies and somemedications (e.g. analgesics), the reason the drug was administered and itseffectiveness.

o The medication record and IV flow sheets are important parts of document action.o The nurses’ responsibility is to record administration of medications promptly to

avoid confusion about missed doses and prevents inadvertent double dosing.o Skin Assessment Recordo A skin or wound assessment is often recorded on a flow sheet.o These records may include categories related to stage of skin injury, drainage, odour,

culture information and treatments. Nursing plan of care

o A nursing plan of care should be generated at admission and revised to reflect changesin the patient’s condition.

o The nursing care plan contains:- Nursing diagnosis Goals of care Outcome criteria Nursing interventions Evaluation

o Nursing care plan must be individualized and often part the permanent patient’s



record. Kardex

o The Kardex is a series of flip cards kept in a portable file.o Information entered on the Kardex includes the following:- Pertinent demographic data, such as name, age, occupation, religion, physician’

name, admission date, diagnosis, major procedures, surgery and date and next ofkin.

List of medications, with date of order and the times of administration for each. List of daily nursing procedures, such as dressing changes, irrigations, postural

drainage or measurement of vital signs. List of diagnostic procedures ordered, such as x-ray or laboratory tests. Allergies Basic needs, such as diet, activity, hygiene, how bowel and urinary elimination is

accomplished, assistive devices and safety precautions. A problem list, stated goals, and a list of nursing approaches to meet the goals and

relieve the problems. Progress records (Nursing progress notes)

o Nursing progress notes are recorded for all patients but vary in format depending onthe setting.

o Narrative notes, SOAP notes DAR notes and PIE notes are descriptive forms ofdocumentation that summarize nursing assessments, interventions and clientresponses.

o They may reflect a specific problem being addressed on the care provided over aspecific period.

Nursing Discharge/Referral Summarieso A discharge note and referral summary are completed when the patient is being

discharged and transferred to another institution or to a home setting where a visit bya community health nurse is required.

o If the discharge plan is given directly to the patient and the family, it is important thatinstructions be written in terms that can be readily understood.

o For example medications, treatments, and activities should be written in layman’sterms.

o If the patient is transferred within the facility, it should include all components of thedischarge instructions, but also describe the condition of the patient before transfer.

o If a patient is being transferred to another institution or to a home setting where a visitby a home health nurse is required, the discharge note takes the form of a referralsummary.

Step 3: Filling System (35 minutes)

Filling system means a plan or method of arranging document in prescribed order. The purpose of filling document is to be able to get quickly and complete information

from them whenever necessary.

Requirements of a Good Filling System Simplicity

o The filling method must be easy to understand and simple to operate Easy access

o Documents should be easily identified and located to enable speedy filling.



Securityo Documents should be safely kept and well preserved

Tracer systemo The where-about of documents removed from the storage must be known

Compactnesso Compactness is needed with regard to both convenient filling and cost of storage

space, but the filling system must also provide ability to expand and contractaccording to the nature of the documents.

Economyo The importance of economy is for both equipment and operation.

Common Ways of Filling Alphabetical Unit numbering Serial numbers Serial – Unit Numbering Family Unit Numbering Straight Numeric Filling Terminal – Digit Filling Middle-Digit Filling Geographical filing These methods can be used separately or in combination. The system to be selected depends upon the needs and conditions of the institution it is

serves. The fundamental importance is to have well-functioning filling system.

Alphabetical Filling Alphabetical filling is a way commonly used method for filling in general. The patient’s file folders are labeled using the patient’s name with the last name followed

by the first name. For example the name John Adams converted to file in the alphabetic order becomes

Adams John. In the alphabetic system the records are filed in a cabinet and the folder is labeled with

the patient’s name preferably on the top tab. This method has the advantage that it does not need a supporting index.

Unit Numbering In a unit numbering system, a patient receives the same medical record number for each

admission to the facility. Therefore the numerical identification of each individual patient is always the same. For

example if a person is born in a facility that uses unit numbering, at birth (admission) thepatient is assigned a number (e.g. MR#001234).

Any subsequent admissions of this patient to the facility would use the same medicalrecord number.

In a unit numbering identification system, the patient’s medical record remains the same,in that facility, throughout the lifetime of the patient.

Medical are not shared and are not reused after a patient dies.Serial Numbering



In serial Numbering system, each time a patient comes to the health facility a newmedical record number is assigned.

In this system, the patient’s folders containing the health record for each visit are not filedin the same folder.

Therefore, the records are not located together on the file shelf.

Serial – Unit Numbering A serial –unit numbering system is a combination of the first two numbering systems

discussed. In this system, the patient receives a new medical record number each time he/she comes

to facility. The difference is that each time the patient receives healthcare, the older records are

brought forward and filed with the most recent visit under a new medical record number. This system requires a cross-reference system from the old medical record number to the

new number in order to locate records.

Family Unit Numbering In health care settings where it is common for an entire family to visit a physician or

clinic, an entire family’s records may be contained in one file folder. This family file is then identified by assigning one medical record number to the entire

family (father/husband, mother/wife, and children). This system is called family unit numbering. The family unit number requires that within the family unit number, each family member

receives his/her own modifier number, which is attached to the family number. Themodifier is a number attached to the Medical Record Number (MR#) using a hyphen.

Each member of the family can be identified by modifier associated with his/her positionin the family: the head of household, 01; spouse, 02; first born, 03; second born, 04; etc

Straight Numeric Filling This system involves placing the folders on the shelf in numeric order. For example

MR# 001234, MR# 0012335, MR# 001522 etc. This filling system is easy for Health Information Management staff to understand Straight numeric filling is best used in a system in which there is minimal activity in the

records once they are filed in the permanent file area. Straight numeric methods usually work well in long-term care facilities.

Terminal – Digit Filling Terminal-digit filling is a system in which the patient’s medical record number is divided

into sets of digits for filling purposes Each of the sets digits is used to file the health record numerically within sections of the

files, beginning with the last set. Terminal-digit filling, and other variations of the digit filling, is common in health care

facilities. The easiest example of terminal-digit filling uses a six-digit medical record number. The six-digit number is separated into three sets of two numbers before filling. For example for Medical Record number (MR#) 012345 the sets would look like this 01-

23-45 The sets of digits have names: The first two numbers are called the tertiary digits, the

second two numbers are called the secondary digits, and the last two numbers are called



the primary digits. To file in terminal-digit order (TD) order) you must locate the section of files that

correspond with the sets, beginning with the primary digit. Then within the primary section locate the secondary digits, and finally file record in

numeric order by the tertiary digits. For example:o Step 1. Separate the medical numbers into the necessary sections. For this example we are using a six-digit number separated into three sections

with two numbers each: MR# 012345 converts to 01-23-45. To file this health records #01-23-45 you would begin with the primary digits 45,

the last two digits of MR# 01-23-45 In the file area, you must locate the primary section 45. All files in primary section will end with the number 45.

o Step 2. In primary section 45, you then search for the middle digits, 23. Remain in section 45, where the bottom two numbers are all the same, and be sure

not to venture into another primary section on the shelf. Find middle digits 22 to 24 because 23 is going to be filed between middle digits

22 – 45 and 24 – 45.o Step 3. Once you have located the appropriate middle-digit section, file the record

numerically by the first two digits. Terminal-digit filling can be modified in several different ways. Some facilities use a larger nine digit medical record number or the social security

number. There are several different ways to separate a nine-digit medical record number

for filling. One method is to have three sections with three numbers each: for example MR#

111222333 converts to 111-222-333 for filling. Another method is to separate the number like a Social Security number, for

example MR# 012345678 converts to 012-34-5678. In a six-digit filling scenario there are 100 primary sections of record, 00 through

99. In a nine-digit filling system there are 1000 primary sections, 000 through 999 Primary sections reaching 1000 require a tremendous file area.

Middle-Digit Filling Terminal-digit filling can be modified into another filling method, middle-digit filling. As in terminal-digit filling, the six-digit number is separated into three sets of two

numbers before filling. MR# 012345 sets would look like this 01-23-45. The following shows middle-digit filling for MR# 012345 Step 1. Separate the medical record number into three sections with two numbers each. MR#

012345 converts to 01-23-45.o In middle-set digit filling begin with middle set of digits, and use that set as the

primary digits; in our example, number 23.o Locate the primary section 23 in the file area.o All files in primary section 23 will have middle sets with the number 23



o Step 2. Remain in section 23.o Be sure not to move another primary section on the shelf.o Find the second set of digits, 01.o Step 3. Remain in section 01-23, and then file the second record numerically by the

tertiary digits 45

Geographical Filing This is based on geographical units like countries, regions, towns, etc. Very often is used in combination with another method. It is satisfactory method for example in business companies where filing according to

places and customers is needed.

Advantages and Disadvantages of different Filling MethodsFilling method Advantages DisadvantagesAlphabetic Easy to learn

Does not require additionalcross-reference to identify afile number.

Works in a smaller healthfacility

Illegible handwriting can causeproblems

Space within the popular letters ofthe alphabet can fill quickly

Can be inefficient for a large healthfacility with a large patientpopulation

Many alternative spelling of namesStraight numericTerminal-digit

Easy to learn Equalizes filing activity

throughout the fillingsections

File activity is concentrated Challenging for some file clerks to

learn; misfiles are often difficult tolocate

Middle-Digit Equalizes filing activitythroughout the fillingsections

Even more challenging for somefile clerks to learn; misfiles areoften difficult to locate

Activity: Small Group Discussion (20 minutes)

DIVIDE students into small manageable groups

ASK them to fill in: Tally sheet for re-attendance and for the new attendances of children under- five years at

the Reproductive and Child Health Clinic MTUHA Book number 7 (Children Register Book)

ASK students how did they feel during the exercise of filling in these forms and books?

SUMMARIZE that the exercise of filling in the tally sheets and MTUHA books intended toequip students in the necessary skills in completing the necessary information before thepatient leaving the health facility

INFORM students that in the health care delivery system, there are varieties of tally sheetsand MTUHA books which need to be completely and accurately filled in before the client orchild goes home or leaves the health facility



Step 4: Retrieving Information (50 minutes)

Retrieve is to find and get back data and information that has been stored in the memoryof a computer.

To retrieve information from the database the program allows you to retrieve itemsquickly by searching under a key word.

Internet searching tools can be used to retrieve information.

The Common Search Tools Gateways Databases Searching engines Gateways A Gateway is a node or network that serves as an entrance to another network. It

organizes information in structured way in general or subject categories. For example:o Yahoo www.yahoo.como WHO A-Z health topics list www.whoinfo/topics/en/o Essential Health Links www.healthnet.org/essential-linkso HINARI/AGORA/OARE

Databaseo A collection of information organized in such a way a computer can quickly select

desired pieces of data.o Is an electronic filing system.o Traditional databases are organized by fields, records and files.o Example: PubMed – a free search tools to a over 19 million citation

Search engineo A program that searches documents for specified key words and returns a list of

document where the key words were found.o On the www, utilizes automated robotics to gather and index information. For

examples google www.google.com google scholar (more academic) yahoo www.yahoo.com

How to Find the Right Information Browsing – slow, sometimes appropriate Site –specific search tools (within bibliographic database) Subject-based information (gateways) Searching engine




ADVANCE PREPARATION: Computers connected with internet


ASK each group to sit around one computer connected with internet

ASK students to practice searching information about advantages and disadvantages ofelectronic record keeping by using internet searching engines (Google and Yahoo)

PASS through groups while practicing retrieving information using internet searchingengines

SUMMARIZE the activity and continue with the following content


Filling system is a plan or method of arranging document in prescribed order. The purpose of filling document is to be able to get quickly and complete information

from them whenever necessary. The methods of filling methods include: Alphabetical, unit numbering, serial numbers,

serial-unit numbering, family-unit numbering, straight numeric filling, terminal-digitfilling, middle-digit filling and geographical filling

To retrieve is to find and get back data and information that has been stored in thememory of a computer

In retrieving information from the database the program allows you to retrieve itemsquickly by searching under a key word.

Internet search tools can be used to retrieve information include Gateways, Databases andSearching engines.


What is Filling system Explain six requirements of a good filling system Explain six (6) common ways of filling system Mention two (2) advantages and two (2) disadvantages of Alphabetic and Terminal

Filling Methods


References

Davis, N, & Lacour N., (2002). Introduction to Health Information Technology. USA:W.B. Saunders Company

Donabebdian, A., (2003). An Introduction to Quality Assurance to Health Care, London:Oxford University Press,



Hornby, A. S. (2000). Oxford Advanced Learner’s Dictionary. (6th ed). UK: OxfordUniversity Press.

Nell Di Lima S., Johns L., Johns & Liebler J. G.,(1998). A Practical Introduction toHealth Information Management .Maryland, USA: Aspen Publishers Gaithersburg

Potter, P. A, Anne Griffin Perry (2005). Fundamentals of Nursing. (6th ed). USA. MosbyInc.

Rosdahl, C.B., (1999). Textbook of Basic Nursing (7th ed)., Philadelphia, USA: LippincottWilliams &Wilkins,.


29NTA Level-4, Semester 2 Session 5: Health Management InformationSystem

Session 5: Health Management Information System


Prerequisite None

Learning TaskBy the end of this session, students are expected to be able to: Differentiate MTUHA tools in primary health facilities Enumerate various HMIS tools and their importance at the work place Utilize the HMIS records appropriately in determining health interventions

Resources Needed: Flipcharts, marker pens, masking tape Black / white board and chalk, white board markers, Projector (LCD) Computer HMIS (MTUHA) tools: Guidelines, tally sheets, data collection tools, summary books

and reporting forms

OVERVIEW OF SESSION


1 05 Minutes PresentationIntroduction and Overview of LearningTasks

2 30 Minutes Presentation MTUHA Tools in Primary Health Facilities

3 30 Minutes PresentationHMIS Tools and Their Importance at theWork Place


Group DiscussionUtilize the HMIS Records Appropriately inDetermining Health Interventions



SESSION CONTENT






Step 2: MTUHA Tools in Primary Health Facilities (30 minutes) The purposes of HMIS (MTUHA) System in Tanzania are:-

o To provide each facility with information which allows the staff to accurately evaluateand then appropriately modify the activities, in order to provide optimal health careand health prevention for its communities.

o To assist the In-charge and Staff in the management of the health facility. Major sources of HMIS (MTUHA) data:-

o Outpatient department (including dental and eye clinics)o Inpatient department (IPD)o Diagnostic services (laboratory and X-ray)o Reproductive child health (RCH)serviceso Pharmacyo Pathology departmento Medical recordso Administrationo Accountso Community (Book 3)

Five sets of tools which are used in health facilitiesMost of these tools are arranged in books. The twelve HMIS (MTUHA) books/registersare arranged as follows:-o Book 1: MTUHA Guidelineso Book 2: Facility and Hospital Summary Booko Book 3: Community Booko Book 4: Ledger Booko Book 5: Outpatient Department Registero Book 6: Antenatal Care Registero Book 7: Child Registero Book 8: Family Planning Registero Book 9: Diarrhoea treatment Corner Registero Book 10: Report Booko Book 11: Dental Registero Book 12: Delivery Register Book

Step 3: HMIS Tools and their Importance at the Work place (30 minutes)

Five sets of HMIS (MTUHA) Tools are:-

Set 1: Guidelines MTUHA guidelines is the book used as a reference or instruction manual to other

books/registers (Books 2 – 12) Each facility is supposed to have one copy accessible to all service providers at all times

Set 2: Data collection Tools (Books/register) These tools are used in collecting the data (Book 3, Book 4, Book 5, Book 6, Book 7,

Book 8, Book 9, Book 11 and Book 12). Two Books which do not have numbers are in-patient and post-natal.



Set 3: Tally Sheets These are four forms used at the facility level to summarize data from specific health

service area in a given period of time. These are:-o Form F201 – Children attendanceo Form F202 – Immunizationo Form F203 – General Tally sheeto Form F204 – Neonatal tetanus

Set 4: Summary (Compilation) Book Summary Book is Book 2, which is used to compile data from different health service

department. In places where computers are available, this can be kept electronically.

Set 5: Reporting Forms These are facilities and district report forms that are used for reporting daily, monthly,

quarterly and annually. Some are found in Book 10 and district processing file (DPF) Reporting forms at facility level are monthly, quarterly, semi-annually and annual forms

which is Book 10 and consists of:-o F001 Staff List Report (annual)o F002 Equipment inventory (annual)o F003 Status of the health facility buildings report (annual)o F004 Management report (quarterly)o F005 Management report (annual)o F006 Maintenance and Rehabilitation report (annual)o F008 Equipment breakdown report (annual)o F009 Notifiable disease/outbreak (emergency)o Reporting forms at district and regional level:- D001 – Staff report D004 – Quarterly management report (one copy is sent to the Ministry of Health

and Social Welfare) D005 – Annual report District processing file (DPF) District report



Step 4: Utilize the HMIS Records Appropriately in Determining HealthInterventions (45 minutes)



SITUATIONYou are working at the Reproductive and Child Health Clinic where a mother brings her onemonth-old child for RCH services. Your responsibility is to provide all the services anddocument the information using the MTUHA tools bearing in mind that this is the first visit.

ASK groups to read the above situation and work on the following questions Name the forms which can be used to record the information Use the above mentioned forms to fill in the information

SUMMARIZE that there are various MTUHA Tools that are used at Facility level. Each ofthese tools has specific function in collecting data in specified areas within the health facility.

Health Management Information system (HMIS) facilitates good management of a healthfacility.o Monitoring the staff: Number of staff, work stations, and work scheduleo Monitoring workloads: Determining proper allocation of the staff based on workloado Monitoring expenditure for improvement, maintenance and salarieso Monitoring and discussion problems, ideas for improvement, special events in staff

meetings and further actions as neededo HMIS facilitates good maintenance of essential equipment in the facility.

HMIS facilitates the projection and procurement of required medical and non-medicalsupplies

HMIS facilitates improvement of the quality of health care provided through:-o Improving coverage of preventive serviceso Lowering the morbidity and mortality in served population


Collecting data and transforming it into information is costly. Both activities must belimited to useful levels.

An effective HMIS will collect only needed data, analyze and organize it into usefulinformation and disseminate it to appropriate individuals in a timely and efficient manner.

Top level managers need information to assist them to plan, and control activities. Middlelevel managers need information to manage their units affectively.

The planning, design, implementation, monitoring and improvements are the major stepsneeded in information management.

Managers need to involve users in managing information and in implementation.Decision making also need to be interactive.




What is HMIS What are the three sets of MTUHA Tools Name five (5) Books used in the HMIS What are the four (4) types of Tally sheets used in HMIS What are the five (5) Report Forms used at district and regional level.


References:

Davis N, & Lacour N., (2002). Introduction to Health Information Technology. USA:W.B. Saunders Company

Deluca, M.J. & Enmark, R. (2002). The CEO Guide to HealthCare Information System(2nd ed.) San Francisco: John Willey & Sons Inc.

MOHSW. (2002). Health Management Information System HMIS (MTUHA) GuidelinesBook 1Ministry of Health & Social Welfare: Dar-es-Salaam Tanzania.

MOHSW. (2002). HMIS Health Evaluation and Planning (HELP) Manual for the In-charges of Health Facilities. Ministry of Health & Social Welfare: Dar-es-SalaamTanzania.

MOHSW (2007). Health Management Information System HMIS (MTUHA) Version 2.0Composite. Ministry of Health & Social Welfare: Dar-es-Salaam Tanzania.


34NTA Level-4, Semester 2 Session 6: Patient Records for Planning andImproving Care

Session 6: Patient Records for Planning and ImprovingCare


Prerequisite None

Learning TaskBy the end of this session, students are expected to be able to: Use legible, concise and logical documentation in collecting patients/clients records Identify ways of eliciting information from patients/clients Determine type of care required for individual patient/client by analyzing

information/records

Resources Needed: Flipcharts, marker pens, masking tape Black / white board and chalk, white board markers, Projector (LCD) Laptop computer

SESSION OVERVIEW




Group DiscussionDocumentation in Collecting Patients/ClientRecords

3 05 MinutesPresentation Identification of ways of Eliciting Information

from Patients/Clients

4 45 MinutesPresentation,Case Study

Determination of Type of Care Required forIndividual Patient/Client by AnalyzingInformation/Records



Resources neededSESSION CONTENT


READ or ASK students to read the Learning tasks and clarify

ASK students if they have any question before proceedingStep 2: Use of Legible, Concise and Logical Documentation (55 minutes)



Activity: Small Group Exercise (55 minutes)

DIVIDE students in small manageable groups

ASK students to go to Medical Wards and assign them to assess the patient and document thefindings

MAKE sure you go with students in the wards

EVALUATE the documentation to see if it legible, concise and logic.

SUMMARIZE: Remind the students to review the qualities of documentation process andcontinue with the following content

Step 3: Ways of Eliciting Information from Patients/Clients (5 minutes)

Observation by use of natural human senses (vision, smell, hearing, touch) Interviewing Review previous records Physical examination/assessment Intuition

Step 4: Analysis of Information/Records Determining Type of Care for theIndividual Patient/Client (45 minutes)

Activity: Case Study (45 minutes)


ASSIGN groups to go the medical wards, to collect and analyze the information recorded in: The graphic sheets. Fluid balance sheets By using the analyzed data, develop a plan of care to a specific patient. Present the developed plan of care for discussion.

SUMMARIZE: The importance of collecting the information accurately and properlyanalyzing it so as to determine the patient’s problems.


The document need to be legible, concise and logical Ways of eliciting information from patients/clients includes observation, interviewing,

Review previous records, physical examination/assessment and intuition Collected information should be analyzed and interpreted for the benefits of patient/client.




What are the ways of eliciting from the patient/client What are the importance of collecting, analyzing and interpreting the information of the

patient.


References

MHSW, (2008). Basic Nursing Procedures.( 3rd ed).Dar Es-Salaam, Tanzania: Ministryof Health and Social Welfare.

Craven, F. R. & Constance J. Hirnle, (2000). Fundamentals of Nursing, (3rd).Philadelphia, USA: .Lippincott Williams & Wilkins

Kozier, B., Glenora, E.R.B., Audrey B. et al. (2004). Fundamentals of Nursing (7th ed).New Jersey, USA: Pearson Education Inc.

Taylor C, Carol Lillis & Priscilla LeMone, (1993). Fundamentals of Nursing, (2nd ed).Philadelphia. USA: J.B. Lippincott Company.

Potter, P. A & Anne Griffin Perry. (2005). Fundamentals of Nursing (6th ed.) USA:Mosby Inc.

Hornby, A. S. (1993). Oxford Advanced Learner’s Dictionary. (4th ed.), UK: OxfordUniversity Press.

Efoghor, J. E. (2010, October 20). 20 Qualities of a Professional Nurse. RetrievedJanuary 5, 2011, from http://ezinearticles.com/?20-Qualities-of-a-Professional-Nurse&id=5239489


37NTA Level-4, Semester 2 Session 7: Confidentiality with Patient/ClientRecords

Session 7: Confidentiality with Patient/Client Records


Prerequisite None

Learning TaskBy the end of this session, students are expected to be able to: Explain the importance of confidentiality in relation to patient/clients records Differentiate between confidential and non-confidential information Describe the procedure for realizing/supplying confidential patients/clients records

Resources Needed Flipcharts, marker pens, masking tape Black / white board and chalk, white board markers, Projector (LCD) Laptop computer

SESSION OVERVIEW


1 05 Minutes Lecture/discussion Introduction and Overview of Learning Tasks


BuzzImportance of Confidentiality in Relation toPatient/Clients Records

3 30 Minutes PresentationConfidential and Non-ConfidentialInformation

4 30 Minutes PresentationThe Procedure for Realizing/SupplyingConfidential Patients/Clients Records

5 05 Minutes Presentation Key points


SESSION CONTENT






Step 2: Importance of Confidentiality in Relation to Patient/Client Records(45 minutes)

Activity: Buzzing (5 minutes)

ASK students to buzz in pairs on ‘the importance of confidentiality of patients/clients recordsfor 2 minutes

ALLOW some few pairs to share their responses

WRITE their responses on the flip chart paper/board

SUMMARIZE their responses and continue with the content below

Ethical Concerns in Documentation and ReportingConfidentiality All patient care must be confidential. This rule is a basic nursing responsibility and a patient expectation. Nurses must treat the patient record as a confidential document entrusted to the healthcare

team. They should never leave it in public areas where it could be read by unauthorized people. Nurses traveling in the community are to keep records in a secured filing system. They are not to discuss or share the contents of the record with anyone not directly

involved in the patient’s care, including the patient’s minister, family members andphysicians and nurses who are friends of the family.

Strangers such as students on a unit should be asked for identification before they areallowed access to the patient’s record.

The patient’s right to privacy must be actively guarded. Discuss patient only in a manner that ensures privacy.

Ensuring confidentiality of Computer Records Health care agencies have developed policies and procedures to ensure the privacy and

confidential of patient information stored in computers. The following are suggestions to ensure the confidentiality of computerized records:-

o Computer programs used for documentation must safeguard the information once it islogged into patient’s record, providing strict and clear recording of any subsequentchanges to entry.

o A personal password is needed to enter and sign off computer files. The passwordshould never be shared with anyone including other health team members.

o After logging on, never leave a computer terminal unattendedo Ensure that only authorized people can view the screen when patient’s information is

displayed.o Share all unneeded computer-generated worksheet.o Know the facility’s policy and procedure for correcting an entry error.o Follow agency procedures for documenting sensitive material such as a diagnosis of

AIDS.o Computers and other electronic devises providing access to the record must be

safeguarded against theft.Step 3: The Difference between Confidential and Non-Confidential



Information (30 minutes)

Confidential information Is the information which is not public domain and which if disclosed would have

significant adverse effects on the supplies or source of information. Is that information which is treated as a secret and get accessed by other users as per

ethical and legal to relevant authorities. Information that cannot be discussed in public or where family or friends of the patient

could over hear

Non-confidential information:- Is the information that the person reading it should be able to understand the argument

made or at the very least and information being provided without disclosing confidentialinformation

Step 4: Procedure for Realizing/Supplying Confidential Patients/clientsRecords (30 minutes)

Any sharing of information even among health professionals is a breach ofconfidentiality.

Sharing of information about a client/ patient health can be made possible within healthcare team directly involved in the care where the patient/ clients has given informedconsent to share.

A breach occurs when information is shared without the patient/ clients informed consent. Requests for concerning a patient should be referred to the clinical supervisor. Patients/ clients information should not be discussed in public areas Patients records should not be taken out of the clinical affiliation site To break confidentiality is a serious matter and require strong evidence to support an

argument.


The nurse has the duty to maintain confidentiality of a patient’s record; this includesspecial measures to protect information stored in computers.

Patient records are legal documents that provide evidence of patient’s care.


What is confidential information How can one ensure confidentiality of computer records What are the difference between confidential and non-confidential information

ASK students if they have any comments or need clarification on any pointsReferences MHSW, (2008). Basic Nursing Procedures.( 3rd ed). Ministry of Health and Social

Welfare: Dar Es-Salaam, Tanzania. Craven, F. R. & Constance J. Hirnle, (2000). Fundamentals of Nursing, (3rd).



Philadelphia, USA: .Lippincott Williams & Wilkins Kozier, B., Glenora, E.R.B., Audrey B.,(2004). Fundamentals of Nursing (7th ed). New

Jersey, USA: Pearson Education Inc. Taylor C, Carol Lillis & Priscilla LeMone, (1993). Fundamentals of Nursing, (2nd ed).

Philadelphia. USA: J.B. Lippincott Company. Potter, P. A & Anne Griffin Perry. (2005). Fundamentals of Nursing (6th ed.) USA:

Mosby Inc. Hornby A. S. (1993). Oxford Advanced Learner’s Dictionary (4th ed.), UK: Oxford

University Press. Efoghor, J. E. (2010, October 20). 20 Qualities of a Professional Nurse. Retrieved

January 5, 2011, from http://ezinearticles.com/?20-Qualities-of-a-Professional-Nurse&id=5239489

Hornby A. S. (1993) Oxford Advanced Learner’s Dictionary 4th ed., Oxford UniversityPress. UK.


41NTA Level-4, Semester 2 Session 8: Legal Limitations in ManagingPatient/Client Records

Session 8: Legal Limitations in ManagingPatient/Client Records


Prerequisite None

Learning TaskBy the end of this session, students are expected to be able to: Explain the legal importance of patient/client records Explain legal implications in relation to patient/client records Explain organizing policy and regulation in handling patients/client record

Resources Needed Flipcharts, marker pens, masking tape Black / white board and chalk, white board markers, Projector (LCD) Laptop computer Worksheet 8.1: Legal Importance of Patient/Client Records

SESSION OVERVIEW


1 05 Minutes Presentation Presentation of Session Title and Leaning Tasks

2 60 MinutesPresentation,Group Discussion

Legal Importance of Patient/Client Records

3 15 Minutes PresentationLegal Implications in Relation to Patient/ClientRecords

4 30 Minutes PresentationOrganizational Policy and Regulation inHandling Patient/Client Records



SESSION CONTENT






Step 2: Legal Importance of Patient/Client Records (60 minutes)

The health record is an important piece of evidence when questions of inadequate,incorrect or poor healthcare arise

Because nurses and other healthcare team members cannot remember specific assessmentor interventions about a patient years after the fact accurate and complete documentationof the time of care is essential

The care may have been excellent, but documentation must prove it.



Refer students to Worksheet 8.1: Legal Importance of Patient/Client Records

FACILITATE the activity as per instructions in the worksheet

SUMMARIZE and clear all the doubts from the students

Step 3: Legal Implications in Relation to Patient/Client Records (15minutes)

Legal awareness Accurate, content documentation should give legal protection to the nurse, the client, the

healthcare facility and the client. Types of legal protection:-

o Adherence to professional standards of nursing careo Agency (institution) policyo Adherence to procedures for interventions and documentation in all situations.o Improving privacy and security practices

Legal issues Some of the legal issues which can be observed in healthcare delivery system are:-

o Failure to keep records as requiredo Inappropriate destruction of documentationo Falsification of clinical recordso Documenting care that never occurredo Signing a document that is known to contain false or misleading informationo Signing for care that was carried out by another person

Step 4: Policy and Regulation in Handling Patients/Client Record (30minutes)Maintenance of the medical records; A medical record shall be maintained for every individual who is evaluated or treated as

an inpatient, outpatient or emergency patient of the hospital or any health facility. The medical records are considered a hybrid record, consisting of both electronic and

paper documentation.



Documentation that comprises the medical records may physically exist in separate andmultiple locations in both paper-based and electronic format.

The medical record contents can be maintained in either paper (hard copy) or electronicformats, including digital images, and may include patient identifiable source ofinformation.

Confidentiality The Nurses and other health personnel should respect the patient confidential

information, except where disclosure is required by a court, or justified in the publicinterest.

The patients has the right to believe that the private and personal information he/she giveswill be only be used for the purposes for which it is given and will not be released toothers without his permission.

In case the information is required for students learning or for research purposes ,in suchcase care must be taken to obtain permission, protect the identity of the patient and ensurethat the notes are not left lying around in public places where access cannot be monitored.

There is a need to obtain the explicitly consent of a patient before disclosure of thespecific information.

The death of a patient does not give you the right to disclose information or to break theconfidentiality.

Disclosure of information should only occurs:o With the consent of the patiento Without the consent of patient when the disclosure is required by law or by order of

court.o Without the consent of the patient when the disclosure is considered to be necessary

in the public interest.

Content: All hospital records and hospital- based clinic records must comply with the applicable

hospital’s medical staff rules and regulations requirements for content and timelycompletion.

All documentation and entries in the medical records, both paper and electronic must beidentified with the patient’s full name and medical record number.

All medical records entries should be made as soon as possible after the care is provided,or an event or observation is made.

Entries should never be made in the medical record in advance of the service provided tothe patient Pre dating or back dating an entry is prohibited.

Security of medical records Medical records shall be maintained in a safe and secured area. Safeguards to prevent loss, destruction and tampering will be maintained as appropriate. Records will be released from the health information management service only in

accordance with the provisions of this policy. Chronology is essential and close attention shall be given to assure that documents are

filed properly, and that information is entered in the correct encounter record for thecorrect patient.

Maintenance and Legibility of Record All medical records, regardless of form or format, must be maintained in their entirety,

and no documents or entry may be deleted from the record, unless with accordance with



the destruction policy.

Corrections and Amendments to Records When an error is made in a medical record entry, the original entry must not be

obliterated, and the inaccurate information should still be accessible.


The health record is an important piece of evidence when questions of inadequate,incorrect or poor healthcare arise

Accurate, content documentation should give legal protection to the nurse, the client, thehealthcare facility and the client.


What are the types of legal protection What are the four legal issues which can be observed in healthcare delivery system


References

Craven, F. R. & Constance J. H. (2000). Fundamentals of Nursing. (3rd). Philadelphia,USA: .Lippincott Williams & Wilkins

Efoghor, J. E. (2010. Qualities of a Professional Nurse. Retrieved January 5, 2011, fromhttp://ezinearticles.com/?20-Qualities-of-a-Professional-Nurse&id=5239489

Hornby A. S. (1993). Oxford Advanced Learner’s Dictionary 4th ed., Oxford UniversityPress. UK.

Hornby, A. S. (1993). Oxford Advanced Learner’s Dictionary. (4th ed.), UK: OxfordUniversity Press.

Kozier, B., Glenora, E.R.B., Audrey B, et al. (2004). Fundamentals of Nursing (7th ed).New Jersey, USA: Pearson Education Inc.

MHSW, (2008). Basic Nursing Procedures.( 3rd ed).Dar Es-Salaam, Tanzania: Ministryof Health and Social Welfare

Potter, P. A & Anne Griffin Perry. (2005). Fundamentals of Nursing. (6th ed.) USA:Mosby Inc.

Taylor C, Carol Lillis & Priscilla LeMone, (1993). Fundamentals of Nursing, (2nd ed).Philadelphia. USA: J.B. Lippincott Company.



Worksheet 8.1: Legal Importance of Patient/Client Records

Read the following situation and identify the possible consequences as instructed belowYou are working in a busy medical unit where your responsibilities include administeringmedication to your patients. In preparing morning medications for a patient you notice thatimportant cardiac medication that should have been given at 6 am was not signed off as givenin the medication record. You consult with another nurse and she states “The night nurseprobably gave the medication and forgot to sign it off. I will just initial the medication and sothat she does not get into trouble with our in-charge.”Questions: Identify possible consequences of this situation to:-

o The patiento The nurse signing off the medicationo The nurse who did not administer the medicationo You who witnessed the act.

How might you respond if you were witnessing this situation? Would your view on the situation differ if the medication was a laxative