Lecture Notes: Informatics and Documentation

Introduction

• Focus: Informatics and documentation in healthcare.
• Communication: Ties closely with informatics and documentation, essential for quality patient care.
  • Poor communication leads to fragmented care and risks of repeated or omitted tasks.

Medical Records

• Legal Record:
  • Permanent, confidential, admissible in court.
  • Access limited to healthcare providers involved in patient care.
• Documentation:
  • Written proof of patient actions and activities.
  • Fundamental in nursing: "If it wasn't documented, it wasn't done."

Documentation Guidelines

• Accreditation Agencies: Joint Commission guidelines.
• Institutional Standards: Be aware of specific documentation requirements.
• Confidentiality: Maintain confidentiality in verbal, written, or electronic forms.

Purpose of Medical Records

• Source of data for healthcare team communication (client needs, treatment response, decision-making).
• **Legal Responsibilities: **Accurate documentation as legal defense.
• Reimbursement: Related to DRGs, severity of illness, service intensity, quality of care.
• Auditing and Monitoring: Required by Joint Commission and CMS.
• Education: Useful for student learning and for research (de-identified data).

Electronic Documentation

• Shift from Paper: American Recovery and Reinvestment Act (ARRA) pushed for EMR adoption.
• Advantages:
  • Remote access, multiple provider access, integration of information.
  • Tracking of access and legibility.
• Disadvantages:
  • Risk of hacking, easy access for nosy staff.
  • Importance of maintaining confidentiality and security.

Standards and Guidelines

• Assessment Documentation: Required for each patient.
• Factual and Accurate: Objective, clear, exact measurements.
• Abbreviations: Use appropriate ones.
• Current and Organized: Timely and logical order of entries.

Legal and Ethical Obligations

• HIPAA Privacy Rule: Protect patient information.
• Access Control: Only for those involved in care.
• Confidentiality Breach: Severe consequences.

Documentation Standards

• Narrative Notes: Different formats like SOAP, DAR, etc.
• Health Record Content: Admission forms, care plans, discharge summaries, etc.
• DAR Documentation:
  • D: Data
  • A: Action
  • R: Response

Communication in Documentation

• Hand-off Reports: Use SBAR.
• Incident Reports: Internal use, not part of permanent record.
• Electronic Medical Record Basics: Log off, don't share passwords.

Health Informatics

• Focus: Application of computer and information science in healthcare.
• Nursing Role: Contribute to system development.
• Clinical Information Systems: Data access and entry.
• CPOE: Streamlines order entry, improves accuracy and speed.

Nursing Informatics

• Growing Field: Opportunities for nurses in IT and informatics.
• Support Systems: Enhance quality and efficiency of care.
• Advantages:
  • More time with patients, better access to information, improved documentation quality.
• Challenges: Initial stress, adapting to new systems.

Security and Privacy

• Risk of Unauthorized Access: Importance of logging off and shredding documents.
• Firewall Protection: Against hacking.

Conclusion

• Communication: Interprofessional communication through documentation.
• Quality Documentation: Accurate, complete, follows guidelines.
• Student Responsibility: Develop knowledge and skills in using information technology in healthcare.