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Confidentiality: What do nurses do, HIPAA requirements
- Nurses are legally and ethically obligated to keep client information confidential.
- Nurses are responsible for protecting records from all unauthorized readers.
- HIPAA act requires disclosures or requests regarding health information standards.
The Joint Commission requires each client have an assessment of:
Physical, psychosocial, environment, self-care, client education, and discharge planning needs.
Who sets nursing documentation standards?
- Federal and state regulations
- State statutes
- Standards of care
- Accreditation agencies
The multidisciplinary communication within the health care team consists of:
- Records or charts
Records or charts are:
confidential permanent legal documents
What form of reports are available?
oral, written, audiotaped exchange of information
A professional caregiver providing formal advice to another caregiver.
- Arrangement for services by another care provider
- Purposes of records
Guidelines for Quality Documentation and Reporting
Methods of recording:
- Narrative: The traditional method
- Problem-Oriented Medical record (POMR):
- - Database
- - Problem List
- - Nursing care plan
- - Progress note (e.g SOAP)
Focus Charting consists of (DAR):
Methods of reporting consists of:
- Source records: A separate section for each discipline
- Charting by exception (CBE): Focuses on documenting deviations
- Case management plan and critical pathways: Incorporates a multidisciplinary approach to care and has common record-keeping forms.
Home Care Documentation:
- Medicare has specific guidelines for establishing eligibility for homecare.
- Documentation is the quality control and jstification for reimbursement from Medicare, Medicaid, or private insurance.
Long-Term Health Care Documentation
- Governmental agencies are instrumental in determining the standards and policies for documentation.
- The Omnibus Budget Reconciliation Act of 1969 includes Medicare and Medicaid legislation for long-term care documentation.
- The department of health in states governs the frequency of written nursing records.
- Software programs allow nurses to enter assessment data.
- Computers generate nursing care plans and document care.
- A complete computer based patient care record (CPCR) is not without legal risks.
What needs to be reported?
- Change of shift
- telephone reports
- verbal or telephone orders
- transfer reports
- incident reports