Basic Patient Care
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
Standards of care
The multidisciplinary communication within the health care team consists of:
Records or charts
Records or charts are:
confidential permanent legal documents
What form of reports are available?
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
Guidelines for Quality Documentation and Reporting
Methods of recording:
: The traditional method
Problem-Oriented Medical record (POMR):
- Problem List
- Nursing care plan
- Progress note (e.g SOAP)
Focus Charting consists of (DAR):
Methods of reporting consists of:
: 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.
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
verbal or telephone orders
Basic Patient Care
Documentation and Informatics