NSE 11A/B Chapter Notes - Chapter 19: Electronic Health Record, Clinical Decision Support System, Client Confidentiality
2 Feb 2019
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Ch19 : Documenting and reporting
· Documentation : nursing action that produces a written account of pertinent ( impt and relevant) data,
nursing clinical decision and interventions and pt responses in a health record – approx. 21.5% of nursing
practice time dedicated to documentation – needs to be accurate and comprehensive as it indicates the
quality of care given
· * recall that the effectiveness of quality of care is dependent on the ability for HCPs to effectively
communication with one another
purposes of medical records
· all impt pt info is entered into the medical records
· data entered facilitates the communication between interdisciplinary care providers and care planning à
indicating, progress responses, pt education, discharge planning, and the medical records are recorded in
the same way that you do nursing process: thus: biographical info, admission method, reason for
admission, brief med-surg history, current meds, pt perception of illness or hospitalization, review of
health risk factors,
· provides legal record of care provided à charting should be performed immediately after care—bc in the
eyes of the law, care not documented is care not provided **
o common mistakes include: failing to record pertinent health or drug info, failiy to
record nursing actions, failing to record meds given, recording on the wrong chart, failing
to document a discontinued med, failing to record drug rxns, or changes in pt condition,
transcribing orders improperly, writing illegibly or incomplete records
· facilitates funding and resource management – shows how health care agency is using their resources or
how their resources are being used
· serve as sources of research data and learning resources for nursing and health care education
· impt in cases of being audited: ie: evaluation of the appropriateness and quality of care provided to pt
the shift to electronic documentation
· electronic health record (EHR): digital version of pt data that is found in traditional records- longitudinal
(LIFETIME) record of all health care encounters for an individual pt
o used to help support effective health care delivery
o want to use it to make a positive impression on the quality of pt care through
interprofessional collaboration with improved data availability and info synthesis and
improving pt safety through the use of clinical decision support pts health record info at
the time and place that clinicians need it
o *key impt thing: EHR has the ability to integrate all of one pt’s encounters with health
care system onto one record
o accurate documentation of info is imperative to meet professional, regulatory and legal
requirements and aids in quality improvement effects and health care research
· electronic medical record (EMR): legal record that describes a SINGLE encounter
o more than 70% of primary care physicians were using it in 2015
*note that EHR and EMR are different and shouldn’t be used interchangeably
confidentiality
· As a professional, the ability to ensure client confidentiality and privacy ( including in the context of
social media), is essential component of nursing education – info should not be shared with people
outside of the health system and other HCPs who are not directly involved in the pt care
· Pts have the right to ask for copies and read their med records – generally need to give written
permission for release of medical records
· Pipeda ( personal information protection and electronic documents act)- u canreview your pt’s med
records only for info needed to provide safe and effective pt care (not allowed to look at other people’s
med records or other pt on the unit)
· Ensure that pt identifiable info isn’t brought home ( ie. files, stickers, infor in notebooks, worksheets etc)
Privacy, confidentiality and security mechanisms
· PIPEDA: personal information protection and electronic documents act: federal legislation that protects
personal information including health info – noting how private sector organizations may collect, use or
disclose peronsl info in the course of commercial activities
· Automatic sign off is a safety mechanism that logs user off cpu system after a certain period of
inactivity + there are firewalls, and installation of antivirus and spyware detection software
o Firewall: combo of hardware and software that protects private network resources ( ie.
info system of the hospital) from outside hackers, network damage, theft or misuse ofinfo
· Passwords are also used to authenticate authorized access- strong passwords consist of letters, numbers
and symbols ( frequent and random changes is needed to ensure security)
Handling and disposing of info
· Ensure that once pt info is no longer needed- anything printed should be shredded or disposed of in
appropriate receptacle
· All papers including patient health info must be discarded to avoid misuse
· Be sure to double check fax numbers and sending the a cover letter so recipient doesn’t have to read to
find out who it’s addressed to
· Use programmed speed dial keys to avoid dialing wrong
· Place fax machine in a safe area and limit machine access to designated individuals
Interprofesionnal communication with the health care team
· Pt record: a confidential, permanent legal document of information relevant to pts health care – info is
recorded after every pt interaction and made available to all relevant hcps – all health records must
contain
o Pt identification and demographic data
o Informed conset for treatment and procedures
o Advance directives
o Admission nursing history
o Nursing diagnoses or problems and the nuring or interdisciplinary care plan
o Record of nursing care treatment and eval
o Medical history
o Medical diagnosis
o Therapeutic orders
o Progress notes for various hcps
o Reports of physical exams
o Reports of diagnostic studies
o Record of pt and family education
o Summary of operative procedures
o Discharge plan and summary
· Reports: oral, written or autdiotaped exchanges of info between caregivers – reports compiled by nurses
include change of shift reports, telephone reports, transfer reports, and incident or occurrence reports
· Consultation: form of discussion where one professional caregiver gives formal advice to another
professional caregiver about the care of pt
Document Summary
Documentation : nursing action that produces a written account of pertinent ( impt and relevant) data, nursing clinical decision and interventions and pt responses in a health record approx. 21. 5% of nursing practice time dedicated to documentation needs to be accurate and comprehensive as it indicates the quality of care given. * recall that the effectiveness of quality of care is dependent on the ability for hcps to effectively communication with one another purposes of medical records. All impt pt info is entered into the medical records. Facilitates funding and resource management shows how health care agency is using their resources or how their resources are being used. Serve as sources of research data and learning resources for nursing and health care education. Impt in cases of being audited: ie: evaluation of the appropriateness and quality of care provided to pt the shift to electronic documentation.
