Chapter 26

Informatics and Documentation

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 Introduction

 Documentation
 Vital aspect of nursing
 Nursing documentation systems
• Should reflect current standards of nursing practice and
minimize the risk of errors
• Need to be flexible enough to allow members of the health
care team to efficiently document and retrieve clinical data,
track patient outcomes, and facilitate continuity of care
 Must document all nursing care provided in the health
record

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 Purposes of the Health Care Record

 Facilitates interprofessional communication

among health care providers
 Legal record of care provided
 Justification for financial billing and
reimbursement of care
 Auditing, monitoring, and evaluation of care
provided
 Education and research

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 Interprofessional Communication
Within the Medical Record (1 of 2)
 The quality of patient care depends on your
ability to communicate with other members of
the health care team.
 When a plan is not communicated to all
members of the health care team, care becomes
fragmented, tasks are repeated, and delays or
omissions in care often occur.

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 Interprofessional Communication
Within the Medical Record (2 of 2)
 Legal documentation
 Accuracy is one of the best defenses for legal claims
 Reimbursement
 Clarifies treatment rendered
 Auditing and monitoring
 Improves quality of care
 Education
 Helps anticipate care needed for the patient
 Research

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The Shift to Electronic Documentation

 HITECH established provisions to promote the

meaningful use of health information technology
(HIT) to improve the quality and value of health
care
 Experts believe that implementing EHRs across
the health care delivery system will decrease
costs and improve the quality of patient care
 Difference between EHR and EMR
 EHR attributes, components, and advantages

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Maintaining Privacy, Confidentiality, and
Security of the Health Care Record
 Nurses are legally and ethically obligated to
keep all patient information confidential.
 Only discuss the patient’s status with members
of the health care team
 Protected health information
 Can use data for research or continuing
education, but need permission

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 Quick Quiz 1 (1 of 2)

1. Information regarding a patient’s health status may not

be released to non–health care team members because:
A. legal and ethical obligations require health care
providers to keep information strictly confidential.
B. regulations require health care institutions to document
evidence of physical and emotional well-being.
C. reimbursement issues related to patient care and
procedures may be of concern.
D. fragmentation of nursing and medical care procedures
may be identified.

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 Quick Quiz 1 (2 of 2)

Answer:
A. legal and ethical obligations require health care
providers to keep information strictly confidential.

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 Privacy, Confidentiality, and Security
Mechanisms
 Electronic documentation has legal risks.
 Most security mechanisms for computerized
information systems use a combination of logical
and physical restrictions to protect information.
 Physical security measures include placing
computers or file servers in restricted areas or
using privacy filters for computer screens visible
to visitors or others without access.

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 Handling and Disposing
of Information
 You must safeguard any information that is
printed from the record or extracted for report
purposes
 Destroy when no longer needed
 De-identify all patient data
 Special considerations for faxing

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 Standards and Guidelines for Quality
Nursing Documentation
 Know standards of your organization
 Documentation needs to conform to standards of
the National Committee for Quality Assurance
(NCQA) and TJC to maintain institutional
accreditation and minimize liability
 Assessment
 Nursing process
 Medical record components

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Guidelines for Quality Documentation

 Factual
 Accurate
 Current
 Organized
 Complete

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 Case Study (1 of 3)

 Mrs. Smith is a 93-year-old patient with fractures

in her lower spine resulting from severe
osteoarthritis that can be treated with surgery.
She reports her pain as 10 out of 10.

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 Case Study (2 of 3)

 While completing Mrs. Smith's admission history,

you find out that she had a total knee
replacement 3 years ago and pain was not well
controlled at that time.
 Mrs. Smith tells you, “I'm dreading surgery. Last
time, I had such pain when I got out of bed.”

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 Quick Quiz 2 (1 of 2)

2. A nurse has just admitted a patient with a

medical diagnosis of congestive heart failure.
When completing the admission paper work,
the nurse needs to record:
A. an interpretation of patient behavior.
B. objective data that are observed.
C. lengthy entry using lay terminology.
D. abbreviations familiar to the nurse.

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 Quick Quiz 2 (2 of 2)

Answer:
B. objective data that are observed.

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 Methods of Documentation

 Documentation of
patient assessment
data
 Flow sheets
 Progress notes
 Charting by
exception

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 Quick Quiz 3 (1 of 2)

3. A nurse records that the patient stated his

abdominal pain is worse now than last night.
This is an example of:
A. PIE documentation.
B. SOAP documentation.
C. narrative charting.
D. charting by exception.

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 Quick Quiz 3 (2 of 2)

Answer:
C. narrative charting.

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Common Record-Keeping Forms within
the Electronic Health Record
 Admission nursing
history form
 Patient care
summary
 Care plans
 Discharge summary
forms

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 Documenting Communication with
Providers and Unique Events
 Telephone calls made to a provider
 Document every phone call you make to a health care
provider.
 Telephone and verbal orders
 Use of VOs is discouraged except in urgent or
emergent situations.
 Incidence or occurrence reports
 An incident or occurrence is any event that is not
consistent with the routine, expected care of a patient
or the standard procedures in place on a health care
unit or within an agency.
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 Acuity Rating Systems

 Nurses use acuity ratings to determine the hours

of care and number of staff required for a given
group of patients every shift or every 24 hours.
 Based on type and number of nursing
interventions required by a patient over a 24-
hour period.
 The acuity level is a classification used to
compare one or more patients to another group
of patients.

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 Case Study (3 of 3)

 Mrs. Smith’s surgery is successful, and she has

been discharged by her physician.
 What are some key points to consider in
providing discharge information?

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 Documentation in the Long-Term
Health Care Setting
 Documentation is governed by individual state
regulations, TJC, and CMS.
 CMS
 Mandates use of the RAI, including the MDS and CAA
 Communication among nurses; social workers;
dietitians; and recreational, speech, physical,
and occupational therapists is essential.

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 Documentation in the
Home Health Care Setting
 Medicare has specific guidelines to establish
eligibility for home care reimbursement.
 Documentation is the quality control and the
justification for reimbursement from Medicare,
Medicaid, or private insurance companies.
 Nurses use two different data sets to document
clinical assessments and care provided in the
home care setting.
 OASIS
 Omaha system

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 Quick Quiz 4 (1 of 2)

4. A patient you are assisting has fallen in the

shower. You must complete an incident
report. The purpose of an incident report is to:
A. exchange information among health care
members.
B. provide information about patients from one
unit to another unit.
C. ensure proper care for the patient.
D. aid in the hospital’s quality improvement
program.
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 Quick Quiz 4 (2 of 2)

Answer:
D. aid in the hospital’s quality improvement
program.

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 Case Management and
Use of Critical Pathways
 Case management
 Incorporates an interprofessional approach to delivery
and documentation of patient care
 Critical pathways
 Interprofessional care plans that identify patient
problems, key interventions, and expected outcomes
within an established time frame
 Variances
 Unexpected outcomes, unmet goals, and
interventions not specified within a critical pathway

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 Informatics and Information
Management in Health Care
 Health care information system (HIS)
 Clinical information system (CIS)
 Nursing clinical information systems (NCIS)
 Clinical decision support systems (CDSS)

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 Nursing Informatics

 Integrates nursing science, computer science,

and information science to manage and
communicate data, information, knowledge, and
wisdom in nursing and informatics practice
 Nursing informatics is also recognized as a
specialty area of nursing practice
 Informatics competences for nursing graduates
entering the workforce

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