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Confidentiality: What do nurses do, HIPAA requirements
Nurses are legally and ethically obligated to keep client information confidential.
Nurses are responsible for protecting records from all unauthorized readers.
HIPAA act requires disclosures or requests regarding health information standards.
The Joint Commission requires each client have an assessment of:
Physical, psychosocial, environment, self-care, client education, and discharge planning needs.
Who sets nursing documentation standards?
Federal and state regulations
State statutes
Standards of care
Accreditation agencies
The multidisciplinary communication within the health care team consists of:
Records or charts
Reports
Consultations
Referrals
Records or charts are:
confidential permanent legal documents
What form of reports are available?
oral, written, audiotaped exchange of information
Consultations are:
A professional caregiver providing formal advice to another caregiver.
Referrals:
Arrangement for services by another care provider
Purposes of records
Guidelines for Quality Documentation and Reporting
Factual
Accurate
Complete
Current
Organized
Methods of recording:
Narrative
: The traditional method
Problem-Oriented Medical record (POMR):
- Database
- Problem List
- Nursing care plan
- Progress note (e.g SOAP)
Focus Charting consists of (DAR):
Data
Action
Response
Methods of reporting consists of:
Source records
: A separate section for each discipline
Charting by exception (CBE)
: Focuses on documenting deviations
Case management plan and critical pathways
: Incorporates a multidisciplinary approach to care and has common record-keeping forms.
Home Care Documentation:
Medicare has specific guidelines for establishing eligibility for homecare.
Documentation is the quality control and jstification for reimbursement from Medicare, Medicaid, or private insurance.
Long-Term Health Care Documentation
Governmental agencies are instrumental in determining the standards and policies for documentation.
The Omnibus Budget Reconciliation Act of 1969 includes Medicare and Medicaid legislation for long-term care documentation.
The department of health in states governs the frequency of written nursing records.
Computerized Documentation:
Software 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.
What needs to be reported?
Change of shift
telephone reports
verbal or telephone orders
transfer reports
incident reports
Author
justbejanice
ID
8779
Card Set
Basic Patient Care
Description
Documentation and Informatics
Updated
2010-03-02T05:33:45Z
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