Chapter 26: Documentation and Informatics

MISTAKES IN DOCUMENTATION THAT COMMONLY RESULTS IN MALPRACTICE

- Failing to record pertinent health or drug information
- Failing to record nursing actions
- Failing to record medication administration
- Failing to record drug reactions or changes in patients’ condition
- Incomplete or illegible records
- Failing to document discontinued medications

LEGAL GUIDELINES FOR DOCUMENTATION

- Do not document retaliatory or critical comments about a patient or care provided by
another HCP. DO not enter personal opinions
 Evidence for nonprofessional behavior or poor quality of care
o Enter only objective and factual observations of a patient’s behavior or the
actions of another HCP. Quote all patient statements
- Correct all errors promptly
 Errors in recording can lead to errors in treatment or may imply an
attempt to mislead or hide evidence
o Avoid rushing to complete documentation
- Record all facts
 Record must be accurate, factual and objective
o A person reading your documentation needs to be able to determine that a
patient received adequate care
- Document discussions with providers that you initiate to seek clarification regarding
an order that is questioned
 If you carry out an order that is written incorrectly, you are just as liable
for prosecution as the HCP
o Do not record “Physician made error.” Instead, document that “Dr. smith was
called to clarify order.” Include date and time of the phone call, with whom you
spoke and the outcome
- Document only for yourself
 You are accountable for information that you enter in a patient’s record
o Never enter documentation for another person. EXCEPTION: if caregiver has left
unit for the day and calls with information that needs to be documented: include
date and time of entry and reference specific date and time to which you are
referring and name of source of information in entry; include that information
was provided via telephone
- Avoid using generalized, empty phrases such as “status has unchanged”
 This type of documentation is subjective and does not reflect patient
assessment
o Use complete, concise descriptions of assessments and care provided so
documentation is objective and factual
- Begin each entry with date and time and end with your signature and credentials
  Ensures that the correct sequence of events is recorded; signature
documents who is accountable for care delivered
o Do not wait until the end of shift to record important changes that occurred
several hours earlier
- Protect the security of your password for computer documentation

EHR vs EMR
- Frequently used interchangeably in practice but there are many differences between
them
- EHR: digital version of patient data that is found in traditional paper records.
o Refers to a longitudinal (lifetime) record of all health care encounters for an
individual patients
o Promise of HER = make a positive impact on the quality of patient care through
interprofessional collaboration with improved data availability and information
synthesis and improving patient safety through the use of clinical decision
support.
o Provides access to a patient’s health record information at the time an d place
that clinicians need it
o Ability to integrate all patient information into one record, regardless of the
number of times a patient enters a health care system
o Also includes results of diagnostic studies that may include diagnostic images
and decision support software programs
- EMR: legal record that describes a single encounter or visit created in hospitals and
outpatient health care settings that is the source of data for the EHR

CONFIDENTIALITY
PRIVACY, CONFIDENTIALITY AND SECURITY MECHANISMS
- 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
o This form of security has limited benefit, especially if an organization uses mobile
wireless devices
o Some organizations use motion detectors or alarms with these devices to
prevent theft
HANDLING AND DISPOSING OF INFORMATION
- Destroy (shred) anything that is printed when the information is no longer needed
- Nursing students must write down patient data needed for clinical paperwork directly
from a patient’s medical record
o You need to de-identify all patient data when you write it onto forms
o Do not remove patient information that is printed from a clinical agency
o Keep the documents secure and destroy documents by shredding or disposing of
them in a locked receptacle
INFORMATION INCLUDED IN ALL MEDICAL RECORDS
- Patient identification and demographic data
- Existence of “living will” or “durable power of attorney for healthcare” documents
- Informed consent for treatment and procedures
- Admission data
- Nursing diagnoses or problems and the nursing or interdisciplinary care plan
- Record of nursing care treatment and evaluation
- Medical history/diagnoses
- Therapeutic orders, including code status
- Medical and interdisciplinary progress notes
- Physical assessment findings
- Diagnostic study results
- Patient education
- Summary or operative procedures
- Discharge summary and plan

STANDARDS
- Current documentation standards require that all patients admitted to a health care
facility have an assessment of physical, psychosocial, environmental, self-care,
knowledge level, and discharge planning needs
o Your documentation needs to demonstrate application of the nursing process
and include evidence of patient and family teaching and discharge planning

GUIDELINES FOR QUALITY DOCUMENTATION

- Quality documentation has 5 important characteristics: It is
o Factual
 Avoid vague terms such as appears, seems, or apparently (stating an
opinion)
 Objective information
 The only subjective data that you should include is what a patient says
o Accurate
 Use exact measurements
 Avoid the use of unnecessary words and irrelevant detail
o Complete
o Current
 Timely entries are essential in a patient’s ongoing care. Document the
following activities or findings at the time of occurrence: vitals, pain
assessment, administration of meds, preparation for diagnostic tests or
surgery, change in patient status
o Organized

METHODS OF DOCUMENTATION
- Narrative Documentation: Traditionally used to record patient assessment and nursing
care provided.
 o The use of storylike format to document information
o Tends to be time consuming and repetitious
o Requires the reader to sort through a lot of information to locate desired data
o Some nurses believe that in certain situations use of this method provides better
detail of individual patient assessment findings and/or complex patient
situations
o EMRs = limitation – some areas are designed to use multiple checkboxes or drop-
down lists
- Problem-oriented medical record: System of organizing documentation to place the
primary focus on patients’ individual problems
o Data are organized by problem or diagnosis
o 4 main sections:
 Database
 All available assessment information pertaining to a patient
 Provides the foundation for identifying patient problems and
planning care
 Problem list
 Includes patient’s physiological, psychological, social, cultural,
spiritual, developmental and environmental needs
 Care plan
 Progress Notes
 Several formats:
o SOAP: Subjective data (verbalizations of the patient);
Objective data (that which is measured and observed);
Assessment (diagnosis based on the data) and Plan (what
the caregivers plan to do)
 I = intervention, E = evaluation

CHARTING BY EXCEPTION
- Philosophy is that a patient meets all standards unless otherwise documented
- Exception-based documentation systems incorporate standards of care, evidence-based
interventions and clearly defined criteria for nursing assessment and documentation of
“normal findings”
o The predefined statements used to document nursing assessment of body
systems are called within defined limits (WDL) or within normal limits (WNL)
definitions
o They consist of written criteria for a “normal” assessment for each body system
- You only write a progress note when a patient’s assessment does not meet the
standardized criteria for “normal” in one or more body systems
- When changes in a patient’s condition develop, you need to include a thorough and
precise description of the effect of the change on the patient and the actions taken to
address the change in the progress note

CASE MANAGEMENT AND USE OF CRITICAL PATHWAYS

 - Case management: model of delivery care
o Incorporates an interprofessional approach to documenting patient care
- Critical pathways: also known as clinical pathways, practice guidelines, or CareMap
tools
o Interprofessional care plans that identify patient problems, key interventions
and expected outcomes within an established time frame
o The document facilitates the integration of care because all health care team
members use the same critical pathway to monitor a patient’s progress during
each shift or home visit
o Many organizations summarize the standardized plan of care into critical
pathways for a specific disease or condition
o Evidence-based critical pathways improve patient outcomes
o Eliminates nurses’ notes, flow sheets and nursing care plans because the
document integrates all relevant information
o Variances: unexpected outcomes, unmet goals and interventions not specified
within the critical pathway
 Occurs when the activities on the critical pathway are not completed as
predicted or a patient does not meet the expected outcomes
 Positive variance = when a patient progresses more rapidly than expected
 Can be negative
 Document all variances in critical pathway

COMMON RECORD-KEEPING FORMS

- Admission Nursing History Form
o Completion of this form provides baseline data that you use for comparison
when a patient’s condition changes
- Flow sheets and Graphic Records
o Allows you to quickly and easily enter assessment data about a patient such as
vitals, admission and or daily weights, and percentage of meals eaten
o Also facilitate the documentation of the provision of routine, repetitive care such
as hygiene measures, ambulation and safety and restraint checks
o Provide current patient information accessible to all members of the health care
team and help team members quickly see patient trends over time
- Patient Care Summary
o Can review and sometimes print for each patient at the beginning/end of each
shift
o Automatically updates and provides the most current information that has been
entered in the HER
- Standardized Care Plans/Clinical Practice Guidelines (CPGs)
o Preprinted, established guidelines to care for patients who have similar health
problems
o Follow nursing process
o These are electronically populated and completed by the nurse and are in the
EMR
 o Facilitates the creation and documentation of a nursing and or interprofessional
plan of care
o CPGs : facilitates safe and consistent care for an identified problem by describing
or listing institutional standards and evidence-based guidelines that are easily
accessed and included in a patient’s HER
o Useful when conducting quality improvement audits
o Also improve continuity of care among professional nurses
o Update care plans or CPGs on a regular basis
- Discharge Summary Forms
o Nurses help ensure cost-effective care and appropriate reimbursement by
preparing patients for an effective, timely discharge from a health care
institution
o Ideally discharge planning begins at admission
 By identifying discharge needs early, nursing and other HCPs begin
planning for discharge to the appropriate level of care
o Involve patient and family
o Discharge documentation includes medications, diet, community resources,
follow-up care, and who to contact in case of emergency or questions

ACUITY RATING SYSTEMS

- Acuity ratings: Nurses use these to determine the hours of care and number of staff
required for a given group of patients every shift of every 24 hours
- A patient’s acuity level, usually determined by assessment data entered into a computer
program by a RN, is based on the type and number of nursing interventions required by
a patient over a 24 hour period
- Although acuity ratings are not part of a patient’s medical record, nursing
documentation within the medical record provides evidence to support the assessment
of an acuity rating for an individual patient
- Acuity level is a classification used to compare one or more patients to another group of
patients
- Patient-to-staff ratios established for a unit depend on a composite gathering of 24 hour
acuity data for all patients receiving care

DOCUMENTATION IN THE HOME HEALTH CARE SETTING

- Nurses use 2 different data sets to document the clinical assessments and care provided
in the home care setting:
o OASIS (Outcome and Assessment Information Set)
 CMS mandates the use of OASIS for collecting and reporting patient
assessments and outcomes in the home health care setting
 Includes a comprehensive admission assessment and calculates clinical,
functional and service scores to provide justification for reimbursement
of services
o Omaha system
  Consists of Problem classification scheme, intervention scheme and
problem rating scale for outcomes
 Provides a useful model for the comprehensive evaluation of nursing care
and evaluates the quality of nursing care provided in the home care
setting

DOCUMENTATION IN THE LONG-TERM HEALTH CARE SETTING

- Includes skilled nursing facilities (SNF) in which patients receive 24-hour-a-day care
- Resident Assessment Instrument: includes the minimum data set (MDS) and Care Area
Assessment (CAA) = data set that is federally mandated for use in long-term care
facilities by CMS
o MDS assessment forms completed on admission and then periodically, within
specific guidelines and time frames for all residents in certified nursing homes

DOCUMENTATING COMMUNICATION WITH PROVIDERS AND UNIQUE EVENTS

TELEPHONE CALLS MADE TO A PROVIDER
- Document when the call was made, who made it for you, who was called, to whom
information was given, what information was given and what information was received
TELEPHONE AND VERBAL ORDERS
- TO’s = occur when a HCP gives therapeutic orders over the phone to an RN
- VO’s = occur when a HCP gives therapeutic orders to an RN while they are standing in
proximity to one another
- Usually occur at night or during emergencies
- Should be used only when absolutely necessary and not for the sake of convenience
- Computerized provider order entry (CPOE): nurse receiving TO or VO enters complete
order into computer software or writes it out on a physician’s order sheet for entry in
the computer asap.
- HCP later verifies the TO or VO legally by signing it within a set time
INCIDENT OR OCCURRENCE REPORTS
- 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
o Patient falls, needlestick injuries, visitor losing consciousness, med errors,
accidental omission of ordered therapies and any circumstances that lead to
injury or pose a risk for patient injury
- They are important part of quality improvement program of a unit
- Must evaluate and document the patient’s response to the incident
- Do not include any reference to an incident in the medical record
o Makes it easier for a lawyer to argue that the reference makes the incident
report part of the medical record and therefore subject to attorney review
- Incident report goes to Risk management

INFORMATICS AND INFORMATION MANAGEMENT IN HEALTH CARE

 - Health informatics: the application of computer and information science in all basic and
biomedical sciences to facilitate the acquisition, processing, interpretation, optimal use
and communication of health-related data
o Focus is patient and the process of care
o Goal is to enhance the quality and efficiency of care provided
- Competence in informatics is not the same as computer competency
- To become competent in informatics you need to be able to use evolving methods of
discovering, retrieving and using information in practice
NURSING INFORMATICS
- Broadly defined as the “use of information and computer technology to support all
aspects of nursing practice, including direct delivery of care, administration, education
and research”
CLINICAL INFORMATION SYSTEMS
- Programs that include monitoring systems; order entry systems; and lab, radiology and
pharmacy systems
- Order-entry systems allow nurses to order supplies and services from another
department
- Computerized provider order entry (CPOE) systems: allow HCPs to directly enter orders
for patient care into hospital information system
o Has built-in reminders and alerts that help a HCP select the most appropriate
medication or diagnostic test
o Direct entry of orders eliminates issues related to illegible handwriting and
transcription errors
o Also potentially speeds the implementation of ordered diagnostic tests and
treatments
o Orders made through CPOE are integrated within the record and sent to the
appropriate departments
- Clinical decision support systems (CDSS): computerized programs used within the
health care setting to aid and support clinical decision making
o Ex.) Notifying HCP of patient allergies before ordering a medication
o Improves nursing care. When patient assessment data are combined with
patient care guidelines, nurses are better able to implement evidence-based
nursing care
NURSING CLINICAL INFORMATION SYSTEMS
- Nursing clinical information system (NCIS): incorporates the principles of nursing
informatics to support the work that nurses do by facilitating documentation of nursing
process activities and offering resources for managing nursing care delivery
- Allows nurses to access computerized information at the patient’s bedside
- Enables the nurse to share care plan immediately with the patient
- Can check on lab results
- Has 2 designs
o Nursing process = most traditional. Organizes documentation within well-
established formats
 o Protocol or critical pathway design = facilitates interdisciplinary management of
information because all HCP use evidenced based protocols or critical pathways
to document the care they provide. Allows a user to select a more appropriate
protocols for a patient. System integrates appropriate information into the
medication delivery process to enhance patient safety. Also identifies variances
of the anticipated outcome on the protocols as documentation is entered.

ADVANTAGES OF A NURSING CLINICAL INFORMATION SYSTEM

- Better access to information
- Enhanced quality of documentation through prompts
- Reduced errors of omission
- Reduced hospital costs
- Increased nurse job satisfaction
- Compliance with requirements of accrediting agencies
- Development of a common clinical database
- Enhanced ability to track records