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Documentation & Informatics

Learning Objectives
1. Describe nursing informatics and its contributions to nursing and healthcare.
2. Discuss legal guidelines for documentation and reporting.
3. Describe different methods of documentation.
4. Discuss the role of the nurse in receiving and transcribing healthcare provider orders.
Health Informatics
Application of computer and information science for managing health-related data
Focus on the patient and the process of care
Goal is to enhance the quality and efficiency of care provided.
Driven by the Health Information Technology for Economic and Clinical Health Act (HITECH)
Benefits of a Health Information Exchange
Provides a vehicle for improving quality and safety of patient care
Provides a basic level of interoperability among EHRs maintained by individual physicians
and organizations
Stimulates consumer education and patients' involvement in their own health care
Helps public health officials meet their commitment to the community
Creates a potential loop for feedback between health-related research and actual practice
Facilitates efficient deployment of emerging technology and health care services
Provides the backbone of technical infrastructure for leverage by national and state-level
Nursing Informatics: A specialty that integrates nursing science, computer science, and
information science to manage and communicate data, information, and knowledge in nursing
Supports the way that nurses function and work
Supports and enhances nursing practice through improved access to information and
clinical decision-making tools
Nursing Information Systems
Increases in the accuracy and completeness of nursing documentation
Improvement in the nurses workflow and an elimination of redundant documentation
Automation of the collection and reuse of nursing data
Facilitation of the analysis of clinical data
o Increased time with patient
o Better access to information
o Reduced errors in omission
o Compliance with accrediting agencies
Nursing Information Systems
Privacy, confidentiality, and security mechanisms
o Legal risks
Handling and disposal of information
Protection of the confidentiality of patients health information and the security of
computer systems are top priorities that include log-in processes, audit trails, firewalls,
data recovery processes, and policies about handling and disposing of data to protect
patient information.
Never share password; Never leave computer unattended after log-in; Follow correct
procedure for correcting errors; Never create, change or delete records w/o the authority

to do so; Dont leave a monitor visible with patient information; Never send protected
health information via e-mail unless it is encrypted
Current documentation standards require that each patient have an assessment:
Physical, psychosocial, environmental, self-care, patient education, knowledge level, and
discharge planning needs
Nursing documentation standards are set by federal and state regulations, state statutes,
standards of care, and accreditation agencies.
What is Confidential?
All information about patients written on paper, spoken aloud, saved on computer. All
information pertaining to a patients health care management that is gathered by
examination, observation, conversation, or treatment is confidential.
Name, address, phone, fax, social security number
Reason the person is sick
Treatments patient receives
Information about past health conditions
Patient Rights
Patients have the right to:
o See and copy their health record
o Update their health record
o Get a list of disclosures
o Request a restriction on certain uses or disclosures
o Choose how to receive health information
Purposes of Patient Records
Diagnostic and therapeutic orders
Care planning
Quality process and performance improvement
Research; decision analysis
Credentialing, regulation, and legislation
Legal and historical documentation
Methods of Documentation
Source-oriented records
Problem-oriented medical records
PIE charting (problem, intervention, evaluation)
Charting by exception
Case management model
Computerized documentation/Electronic health records (EHRs)
Formats for Nursing Documentation
Initial nursing assessment
Patient care summary
Critical collaborative pathways
Care plan
Progress notes
Flow sheets and graphic records
Medication record; Acuity record

Discharge and transfer summary; Long-term care documentation

Home Care Documentation

Medicare has specific guidelines for establishing eligibility for home care.
Medicare guidelines for establishing a patients home care cost reimbursement serve as
the basis for documentation by home care nurses.
Documentation is the quality control and justification for reimbursement from Medicare,
Medicaid, or private insurance.
Nurses need to document all their services for payment.
Quality Documentation and Reporting:
Consistent with professional and agency standards, Complete, Concise, Accurate, Factual,
Organized and timely, Legally prudent, Confidential
Quality Documentation and Reporting: The following nursing care must be documented at the
time of occurrence:
Vital signs
Pain assessment, also referred to as the fifth vital sign
Administration of medications and treatments
Preparation for diagnostic tests or surgery
Change in patient status and who was notified
Treatment for sudden changes in patient status
Patient response to intervention
Preoperative checklist
Admission, transfer, discharge, or death of patient

suspicious entries
A clinical record can look legally suspicious if any of the following appear:
Blank lines
Scribbled out entries
Entries out of chronological order without an explanation (Late entries)
Entries written between lines, with arrows or in margins

Telephone reports and orders
o Situation-background-assessment-recommendation (SBAR)
o Document every call
o Read back
Incident or occurrence reports
o Used to document any event that is not consistent with the routine operation of a
health care unit or the routine care of a patient
o Follow agency policy

for Receiving Verbal Orders in an Emergency

Record the orders in patients medical record.
Read back the order to verify accuracy.
Date and note the time orders were issued in emergency.
Record verbal order and name of the physician issuing the order, followed by nurses
name and initials.

Policy for Physician Review of Verbal Orders

Review orders for accuracy.
Sign orders with name, title, and pager number.

Date and note time orders signed.

Duties of RN Receiving Telephone Orders

Record the orders in patients medical record. *Read orders back to practitioner to verify
Date and note the time orders were issued. *Record telephone orders, and full name and
title of physician or nurse practitioner who issued orders. *Sign the orders with name and