ConfidentialityNurses are legally and ethically

obligated to keep client information confidential.

Nurses are responsible for protecting records from all unauthorized readers.

HIPAA act requires disclosure or requests regarding health information.

StandardsThe Joint Commission requires each

client have an assessment:Physical, psychosocial, environment, self-

care, client education, and discharge planning needs

Federal and state regulations, state statutes, standards of care, and accreditation agencies set nursing documentation standards.

Multidisciplinary Communication Within the Health Care TeamRecords or chart:

Confidential permanent legal document

Reports:Oral, written, audiotaped exchange of

information

Consultations:A professional caregiver providing formal advice

to another caregiver

Referrals:Arrangement for services by another care

provider

Purposes of RecordsCommunicationCommunication Legal documentationLegal documentation

Financial billingFinancial billing EducationEducation

ResearchResearch Auditing/monitoringAuditing/monitoring

Guidelines for Quality Documentation and ReportingFactualAccurateCompleteCurrent Organized

Methods of Recording

Narrative:The traditional method

Problem-Oriented Medical Record (POMR):DatabaseProblem listNursing care planProgress note

Methods of Recording: Progress NotesSOAP:

Subjective, objective, assessment, plan

SOAPIE:Subjective, objective, assessment, plan,

intervention, evaluation

PIE:Problem, intervention, evaluation

Focus Charting (DAR):Data, action, response

Methods of ReportingSource records:

A separate section for each disciplineCharting by exception (CBE):

Focuses on documenting deviationsCase management plan and critical

pathways:Incorporates a multidisciplinary

approach to care

Common Record-Keeping FormsAdmission nursing history Admission nursing history

formformFlow sheets and graphic Flow sheets and graphic

recordsrecords

Client care summary or Client care summary or KardexKardex

Acuity recordsAcuity records

Standardized care plansStandardized care plans Discharge summary formDischarge summary form

Home Care DocumentationMedicare has specific guidelines for

establishing eligibility for home care.Documentation is the quality control

and justification for reimbursement from Medicare, Medicaid, or private insurance.

Nurses need to document all their services for payment.

Long-Term Health Care DocumentationGovernmental agencies are instrumental in

determining the standards and policies for documentation.

The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation.

The department of health in states governs the frequency of written nursing records.

Computerized DocumentationSoftware programs allow nurses to

enter assessment data.Computers generate nursing care plans

and document care.A complete computer-based patient

care record (CPCR) is not without legal risks.

ReportingChange of shiftTelephone reportsVerbal or telephone ordersTransfer reportsIncident reports