Risk Management, Documentation, and Informatics

documentation
Anything written or printed you rely on as record or proof for authorized persons
Medical record is a legal document
Accreditation
The Joint Commission
Diagnostic Related Group (DRG)
Clusters groups together by medical diagnosis
HIPAA
purpose of the record
Communication
Legal Documentation
Financial Billing
Education
Research
Auditing-Monitoring
critical items to documentation
Reflects the nursing process
Describes patient progression from shift to shift or visit to visit for outpatient settings
Plan of care and medical record should compliment each other
Used for quality improvement activities and research
Supports staffing mix and acuity level
common legal documentation mistakes
Failing to record pertinent health or drug information
Failing to record nursing actions
Failing to record that medications have been given
Failing to record drug reactions or changes in patient condition
Writing illegible or incomplete records
Failing to document a discontinued medication
effective documentation
Factual
Accurate
Complete and Organized
Current
progress notes!
SOAP
-Subjective, objective, assessment, plan
SOAPIE
-Subjective, objective, assessment, plan, intervention, evaluation
PIE
-Problem, intervention, evaluation
FOCUS (DAR)
-Data, action, response
Which of the following dosages is most likely to be misinterpreted?
10000 units
10,000 units
1 mg
0.5 mg

answer: 10000 units

The Electronic Health Record
Longitudinal electronic record of client health information generated by one or more encounters in any care delivery system.
Nursing minimum data set
Nursing care elements
-Patient demographic elements
-Service elements
Benefits of EMR/EHR
Legible
Reduced risk of error
More money for organization
Saves time
Disadvantages of EMR/EHR
Costly- initially
Changes in workflow
Design is not perfect
Privacy and security
Training time
System can crash
System errors or flaws
reporting
Change-of-shift report
Telephone reports
Telephone or verbal orders
Transfer reports
Incident reports
conferring about care
Referrals/Consultations
Nursing and interdisciplinary care rounds
Nursing care rounds
Nursing Informatics
Integrates nursing science, computer science, and information science to communicate data, information, and knowledge in nursing practice
Benefits:
-Increase accuracy and completeness of documentation
-Improve nurses’ work flow and redundant documentation
-Automation of collection of nursing data
-Help with analysis of clinical data (TJC indicators etc)
social media and health care
Fosters professional connections

Promotes timely communication with patients and family members

Educates and informs consumers and health care professionals

Social Media and Policies
Hospital policies
May limit what social media may be accessed from work computers or during work time

Often do not address use of social media at home

ANA and NCSBN

Nursing schools

Confidentiality and Privacy
Nurses must safeguard patient information

Share information only with team members who must know unless:

Informed consent
Legally required
Failure to disclose could result in significant harm

HIPAA and Social Media
HIPAA protects patient privacy by defining individually identifiable information

How
Whom
What

Avoiding Problems
Remember legal and ethical obligations to maintain privacy and confidentiality
Never transmit patient-related image via electronic media
Only give information to those who need to know to provide care or due to legal obligation
Be cautious with “friending” patients
consequences
Allegations may include:
Unprofessional conduct
Unethical conduct
Moral turpitude
Revealing a privileged communication
Breach of confidentiality

If found true, may face disciplinary action by the Board of Nursing including reprimand, assessment of monetary fine, or temporary or permanent loss of licensure

other consequences
Civil and criminal penalties
Fines or jail time
Sued for defamation or invasion of privacy

May raise liability under federal regulations focused on preventing patient abuse or exploitation

Termination from employer
May subject organization to a law suit

Social media posts that will destroy your nursing career before it begins
Don’t post references to illegal drug use
Don’t write about excessive alcohol consumption
Avoid illegal activity
Use proper grammar
No swearing on social media
Clean up your past posting history
Update your privacy settings7