ppt chapter 09
TRANSCRIPT
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Chapter 9
Recording and Reporting
Chapter 9
Recording and Reporting
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• Medical records are written collections of information about a person’s health, the care provided by health practitioners, and the client’s progress
– Also known as health records or client records
Medical Records Medical Records
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QuestionQuestion
•Is the following statement true or false?
Medical records cannot be shared among health care workers.
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AnswerAnswer
False.
Medical records are a means to share information among health care workers to ensure client safety and continuity of care.
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• Permanent account
• Sharing information
• Quality assurance
• Accreditation
• Reimbursement
• Education and research
• Legal evidence
Uses of Medical RecordsUses of Medical Records
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• Joint Commission on Accreditation of Healthcare Organizations (JCAHO) establishes criteria reflecting high standards for institutional health care
• Representatives of JCAHO periodically inspect health care agencies and determine evidence of quality care
• Based on inspection, agencies are accredited
JCAHOJCAHO
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• Person’s health information
• Care provided by health practitioners
• The client’s progress
• The plan for care
• Medication administration record
• Laboratory and diagnostic reports
Components of Medical RecordsComponents of Medical Records
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Insert Table 9-1
Components of Medical RecordsComponents of Medical Records
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Source-Oriented RecordsSource-Oriented Records
• Organized according to source of documented information
• Contain separate forms for physicians, nurses, dietitians, physical therapists to make written entries about their specific activities in relation to client’s care
• This record provides fragmented documentation
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Problem-Oriented RecordsProblem-Oriented Records
• Organized according to client’s health problems
• Four major components: data base, problem list, plan of care, progress notes
• Information compiled and arranged to emphasize goal-directed care; promote recording of pertinent information; facilitate communication among health care professionals
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Components of Problem-Oriented Records
Components of Problem-Oriented Records
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QuestionQuestion
•Is the following statement true or false?
Source-oriented records contain separate forms for all entities to make different entries.
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AnswerAnswer
True.
Source-oriented records contain separate forms for physicians, nurses, dietitians, and physical therapists to make written entries about their specific activities in relation to client’s care.
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Methods of ChartingMethods of Charting
• Narrative charting
• SOAP charting
• Focus charting
• PIE charting
• Charting by exception
• Computerized charting
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QuestionQuestion
•Which of the following charting methods involves writing information about the client and client care in chronologic order?
a. SOAP
b. PIE
c. Narrative
d. Focus
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AnswerAnswerc. Narrative charting
Narrative charting involves writing information about the client and client care in chronologic order. SOAP charting involves documenting client data under four essential components. Focus charting is a modified form of SOAP charting. PIE charting is a method of recording the client’s progress under the headings of problem, intervention, and evaluation.
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HIPAAHIPAA
• HIPAA legislation protects the rights of U.S. citizens to retain their health insurance
– Requires health care agencies to safeguard written, spoken, and electronic health information
– Health care agencies must obtain authorization from client to release information to family or friends, attorneys, or for other uses
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HIPAA (cont’d)HIPAA (cont’d)
• Submits written notice to all clients identifying uses and disclosures of health information
• Obtains client’s signature indicating knowledge of disclosure of information and right to learn who has seen his records
• Limits casual access to identity of client and health information
• Health agencies must ensure protection of electronic data
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Beneficial DisclosureBeneficial Disclosure
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Workplace ApplicationsWorkplace Applications
• Client names on charts no longer visible to public
• All clipboards must obscure private client data, including name
• Whiteboards cannot link client name with diagnosis, procedure, or treatment
• Computer screens not visible to public; flat screen monitors recommended
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Workplace Applications (cont’d)Workplace Applications (cont’d)• Conversations regarding clients must occur
in private places
• Fax machines and medical records must be limited to areas inaccessible to public
• Cover sheet on all faxes; emails warning that confidential information being transmitted
• Light boxes (for x-ray, scan results) must be located in private areas
• Documentation must be kept on all with access to client records
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Aspects of DocumentationAspects of Documentation
• The type of information recorded
• The people responsible for charting
• The frequency for making entries on the record
• The type of response given for the information recorded
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Nursing DocumentationNursing Documentation
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AbbreviationsAbbreviations
• Abbreviations shorten length of documentation and documentation time
• Agencies provide list of approved abbreviations and their meanings
• Use only abbreviations on agency’s approved list
• Use JCAHO “Do Not Use” list to avoid and reduce medical errors
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Common AbbreviationsCommon Abbreviations
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Documentation TimeDocumentation Time• Traditional time
– Two 12-hour revolutions; identified with hour and minute, followed by a.m. or p.m.
• Military time– Based on 24-hour clock; uses different
four-digit number for each hour and minute of the dayo First two digits indicate hour within 24-
hour periodo Last two digits indicate minutes
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Documentation Time (cont’d)Documentation Time (cont’d)
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Documentation Time (cont’d)Documentation Time (cont’d)
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QuestionQuestion
•Is the following statement true or false?
Military time is based on two 12-hour revolutions.
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AnswerAnswer
False.
Military time is based on the 24-hour clock while traditional time is based on two 12-hour revolutions.
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Charting GuidelinesCharting Guidelines
• Should not be time-consuming to write and read
• Everyone involved in the care of a client should make entries in the same location in the chart
• The nurse should address specific content in charted progress notes
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Charting Guidelines (cont’d)Charting Guidelines (cont’d)
• Assessments should be documented on a separate form and give the client’s problems a corresponding number for quick access
• Abnormal assessment findings, or care that deviates from the standard, should also be documented separately
• Client information should be documented electronically
• Information should always be legible
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Charting Guidelines (cont’d)Charting Guidelines (cont’d)
• Abbreviations and terms should be consistent with agency-approved lists
• The date of the documentation should be recorded
• The time of the documentation should be recorded
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Written Forms of CommunicationWritten Forms of Communication
• Nursing care plan: list of client’s problems, goals, and nursing orders for client care
• Nursing Kardex: quick reference for current information about client and client care
• Checklists: documentation with check mark or initials
• Flow sheets: documentation with sections for recording frequently repeated assessment data
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Nursing KardexNursing Kardex
(Refer to Figure 9-8 in the textbook.)
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Other Forms of CommunicationOther Forms of Communication
• Change of shift reports
• Client assignments
• Team conferences
• Rounds
• Telephone calls
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QuestionQuestion
•Is the following statement true or false?
A nursing Kardex is a documentation with sections for recording frequently repeated assessment data.
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AnswerAnswer
False.
Nursing Kardex is a quick reference for current information about client and client care.