Basic Patient Care

• 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.

Physical, psychosocial, environment, self-care, client education, and discharge planning needs.

• Federal and state regulations
• State statutes
• Standards of care
• Accreditation agencies

• Records or charts
• Reports
• Consultations
• Referrals

confidential permanent legal documents

oral, written, audiotaped exchange of information

A professional caregiver providing formal advice to another caregiver.

• Arrangement for services by another care provider
• Purposes of records

• Factual
• Accurate
• Complete
• Current
• Organized

• Narrative: The traditional method
• Problem-Oriented Medical record (POMR):
• - Database
• - Problem List
• - Nursing care plan
• - Progress note (e.g SOAP)

• Data
• Action
• Response

• 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.

• Medicare has specific guidelines for establishing eligibility for homecare.
• Documentation is the quality control and jstification for reimbursement from Medicare, Medicaid, or private insurance.

• 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.

• 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.

• Change of shift
• telephone reports
• verbal or telephone orders
• transfer reports
• incident reports