DOCUMENTATION Part 1

If you didn't chart it, it didn't happenPart 1

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documentation

documentation table of contents

Electronic health records

privacy & confidentiality

Documentation Guidelines

What is documentation?

Patient health record (PHI)

written or electronic

What is documentation?

what is documentation?

Centralized source of information. Why is this helpful? Click each number to find out more.

COMMUNICATION!

what is documentation?

Nursing care, treatment, medications, etc.

orders

Admission, medical/surgical history

history

Goals, outcomes, interventions, evaluation

care plan

Treatment/procedures

consent

Problem list

diagnoses

ID, address, phone number

Demographics

what is included?

*click on each to learn more*

DECISION ANALYSIS

LEGAL

EDUCATION

ACCREDITING & CREDENTIALING

RESEARCH

QUALITY PERFORMANCE & IMPROVEMENT

IMPORTANCE OF DOCUMENTATION

*click on each to learn more*

PLAN PATIENT CARE

REIMBURSEMENT

AUDITING

IMPORTANCE OF DOCUMENTATION

Watch this video on the importance of documentation

electronic health record

• Most facilities moving towards EHR
• "Paperless" charting - most facilities still have some type of hardback chart
• Easy for multiple providers read/use
• Standardized format

privacy & confidentiality

• HIPAA - Health Insurance Portability and Accountability Act
• 1996
• Federal law
• National standards to protect sensitive patient information

• All information is PRIVATE & CONFIDENTIAL
• Only those caring for the patient should have access
• Patients are allowed to see and request health record from Medical Records

patient information

privacy & confidentiatliy

Click on each button below to learn more

Health Information Exchange (HIE)

Is this considered a breech in privacy?

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TRUE

FALSE

Question 1/5

False

True

You are a nursing student and you overhear two nurses discussing a surgery they just saw on a patient who was having a triple bypass while in the elevator. This is considered a breech in privacy.

TRUE

Next Question

True

Patient care should never be discussed in public areas.

Question 1/5

You are working with a new graduate nurse and a more experienced nurse asks her for her password so she can help her chart. The graduate nurse states that she will not share her password. This is a breech of patient privacy.

Question 1/5

False

True

False

FALSE

Next Question

The new graduate nurse did the right thing in this situation. Passwords should never be shared to protect patient privacy.

Question 2/5

Question 3/5

False

True

A nurse goes home after a long shift and decides to post a picture on Snapchat saying "Nothing like caring for a patient who just had an amputation." This is considered a breech in patient privacy.

TRUE

Next Question

True

Posting on social media is a breech in patient privacy. Even if a nurse posts something without a patient name or room number, HIPAA covers ANY identifiable information (the amputation).

Question 3/5

Question 5/5

False

True

You are working on a medical surgical unit and sit down at a computer to chart. Your coworker, Susie Bones, has left the EMR up and signed in from her charting. This is considered a breech of privacy.

TRUE

True

Yes, this is a breech in patient privacy. Anyone could walk by and access the computer looking at patient's confidential information. You should always lock your work station when you are done charting and plan to leave the computer.

Question 5/5

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violating hipaa can result in up to $250,000 fines or jail time!

how can we prevent a breech in privacy?

privacy & confidentiatliy

What should be documented?ANY interaction with the patient! Click + for examples

DOCUMENTATION GUIDELINES

Errors

• Must be documented per facility policy
• Single line through written chart
• Edit entry on EMR

Patient Findings

• Avoid generatlizations (good, normal, etc.)
• NO opinions

• CHART ONLY FACTS!

Nursing process

• This includes every step of the nursing process
• Assessments, Interventions, Outcomes, Evaluations, Education

Guidelines for documentation

Content

When you chart you must be COMPLETE, ACCURATE, FACUTAL

Military time

• 0000 = midnight
• 0100 = 1 am
• 1300 = 1 pm
• Don't use : in between hours and minutes

Timely

• Charting must be done in timey manner
• What do you do if you forget?

Guidelines for documentation

Timing

WHEN should I chart? How often?

Accountability

• ALWAYS sign your name and credentials
• NEVER use white out on paper charts
• PERMANENT document - only black ink

Legible

• Neat handwriting!
• Only use abbreviations appropriate and approved by facility
• LOOK it up if you don't know how to spell it!

Guidelines for documentation

Format

Do I have the right chart? Do I have the right patient? Am I charting in the right place?

click here

Legible

• One single black line to the end
• Why would we do this?

Guidelines for documentation

Format

What do I do if there is extra space at the end of a line and I'm paper charting?

ORGANIZED

ACCURATE

TIMELY

SEQUENTIAL

CHARTING MUST BE

Examples of actual documentation that has been found in patient's medical charts

Allows providers to share vital information and helps with

• Avoiding readmissions
• Medical errors
• Improving diagnoses
• Decreasing duplicate testing

What can you do?

• Secure disposal containers
• Shred bins located at every nurse's station
• If you throw something in the trash make sure it has NO patient information (including patient stickers)

Lorem ipsum dolor

ALWAYS make one single black line to the end of that line, then add your signature.

What can you do?

• Don't discuss patien't care in public areas
• Elevators
• Cafeteria
• Hallways
• NO POSTING ON SOCIAL MEDIA!

What can you do?

• Assess patient in private
• Assure that report is given in private
• Include only those involved in patient's care into shift report

Improves:

• Speed
• Quality
• Safety
• Cost of patient care

What can you do?

• No computer access in public areas
• Think nurses station
• In the hallways
• Rooms with other patients (Shared rooms)

• ALL of a patient's health information is located in one centralized location

• ALL important health information
• Includes: assessing, diagnosis, planning, implementing, and evaluating

• Allows doctors, nurses, physical therapists, other healthcare providers to appropriately access patient information