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Key Concepts, Chapter 16, Documenting, Reporting, Conferring, and Using Informatics

Effective communication among health care professionals is essential for coordination

and continuity of care. The three forms of communication central to nurses professional

role are documenting, reporting, and conferring.


Documentation is the written or typed legal record of all pertinent interactions with the

patientassessing, diagnosing, planning, implementing, and evaluating.


The patient record is a compilation of a patients health information. Each health care

institution or agency has policies that specify the nurses documentation responsibilities.
The American Nurses Association (ANA) identifies the following characteristics of

effective documentation: accessible; accurate, relevant, and consistent; auditable; clear,

concise, and complete; legible/readable (particularly in terms of the resolution and related

qualities of electronic health record [EHR] content displayed on the screens of various

devices); thoughtful; timely, contemporaneous, and sequential; reflective of the nursing

process; and retrievable on a permanent basis in a nursing-specific manner.


All information about patients is considered private or confidential, whether written on

paper, saved on a computer, or spoken aloud.

Professional codes of ethics, agency policies, and state and federal privacy legislation

dictate how patient information can be communicated (verbally and in writing), where

and how it can be stored, the appropriate people and entities to whom it may be divulged,

and the purposes for which it may be divulged. Nurses must be familiar with these

guidelines.

Most agencies have specific policies for patient records. Everyone with access to the

record is expected to maintain its confidentiality. Most agencies grant student nurses

access to patient records for education purposes, in which case the student assumes

responsibility to hold patient information in confidence.


Students should minimize the use of abbreviations and instead write or type out the full

terminology or name in order to create a clear record for the caregivers who follow.
Patient records serve many purposes. The ANA writes that the most important of these is

communicating within the health care team and providing information for other

professionals, primarily for individuals and groups involved with accreditation,

credentialing, legal, regulatory and legislative, reimbursement, research, and quality

activities.
With EHRs, data can be distributed among many caregivers in a standardized format,

allowing them to compare and uniformly evaluate patient progress easily. Besides

tracking the progress of individual patients, computerized outcome information can

compare the progress of groups of patients with similar diagnoses. These results

contribute to research, education, and improved and more efficient nursing practice.
An electronic health information exchange (HIE) allows doctors, nurses, pharmacists,

other health care providers and patients to appropriately access and securely share a

patients vital medical information electronicallyimproving the speed, quality, safety,

and cost of patient care.


The chief reason for creating a personal health record is to provide easy access to up-to-

date, complete health information to assist in self-care and communication with

providers.
A source-oriented paper record is one in which each health care group keeps data on its

own separate form. Sections of the record are designated for nurses, physicians,

laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the

most recent entry nearest the front of the record.


The problem-oriented medical record (POMR) is organized around a patients problems

rather than around sources of information. With POMRs, all health care professionals

record information on the same forms. The advantages of this type of record are that the
entire health care team works together to identify a master list of patient problems and

contributes collaboratively to the plan of care.


Other documentation methods include SOAP (Subjective data, Objective data,

Assessment [the caregivers judgment about the situation], Plan); PIEProblem,

Intervention, Evaluation; focus charting; charting by exception (CBE); and case

management model.
Formats for nursing documentation include the initial nursing assessment, care plan,

patient care summary, critical/collaborative pathways, progress notes, flow sheets and

graphic record, medication record, and acuity records.


At the time a patient is discharged from care or transferred from one unit or institution or

agency to another, a discharge summary is written that concisely summarizes the reason

for treatment, significant findings, the procedures performed and treatment rendered, the

patients condition on discharge or transfer, and any specific pertinent instructions given

to the patient and family.


Special guidelines exist for home health care and long term care documentation.
To report is to give an account of something that has been seen, heard, done, or

considered. Reporting is the oral, written, or computer-based communication of patient

data to others.
The trend is toward a standardized, streamlined shift report system at the bedside, which

is driven by patient safety and enhanced patient/family participation.


An incident report, also termed a variance or occurrence report, is a tool used by health

care agencies to document the occurrence of anything out of the ordinary that results in or

has the potential to result in harm to a patient, employee, or visitor. These reports are used

for quality improvement and should not be used for disciplinary action against staff

members.
When nurses detect problems they cannot resolve because they are outside the scope of

independent nursing practice or their expertise, they make consultations or referrals to

other professionals.
Nursing informatics is a specialty that integrates nursing science, computer science, and

information science to manage and communicate data, information, and knowledge in

nursing practice. Nursing informatics facilitates the integration of data, information, and

knowledge to support patients, nurses, and other providers in their decision making in all

roles and settings.

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