BAKERSFIELD COLLEGELICENSED VOCATIONAL NURSING PROGRAM1ST SEMESTER FUNDAMENTALSPROFESSIONAL STANDARDS IN NURSING PRACTICECHAPTER 26 - DOCUMENTATION AND INFORMATICSINTRODUCTIONRecording and reporting are methods the nurse uses in communicating a client’s changinghealth care needs. All health care members rely on accurate and comprehensive reports and records to administer goal-directed care.OBJECTIVESUpon completion of this unit, the student will be able to:A. Theory1. Define selected terms associated with reporting and recording.2. State the guidelines for effectively communicating through reporting and recording.3. Describe two common forms of reporting client information to health care team members.4. Identify ways to maintain confidentiality of records and reports.5. Explain how to verify telephone reports.6. Describe when an incident report would be made and identify reasons that would warrant this report.7. List the six purposes of a health care record.8. State the legal guidelines for charting.9. Differentiate between a source record and a POMR.10. Identify the letters in the acronyms SOAP and PIE.11. Identify and define medical abbreviations from a given list.ASSIGNMENTA. Read Chapter 26- Potter & Perry – Critical Thinking Exercises # 1,3,4, and Review Questions B. Study Guide for Chapter 26Chapter 26 Documentation and Informatics Confidentiality Nurses are legally and ethically obligated to keep client information confidential. Nurses are responsible for protecting records from all unauthorized readers. HIPAA act requires disclosure or requests regarding health information. Standards The Joint Commission requires each client have an assessment: Physical, psychosocial, environment, self-care, client education, and discharge planning needsFederal and state regulations, state statutes, standards of care, and accreditation agencies set nursing documentation standards Multidisciplinary Communication Within the Health Care Team Records or chart: Confidential permanent legal document Reports: Oral, written, audiotaped exchange of information Consultations: A professional caregiver providing formal advice to another caregiver Referrals: Arrangement for services by another care provider Purposes of Records Guidelines for Quality Documentation and Reporting Factual Accurate Complete Current  OrganizedMethods of Recording Narrative: The traditional method Problem-Oriented Medical Record (POMR): Database Problem list Nursing care plan Progress note Methods of Recording: Progress Notes SOAP: Subjective, objective, assessment, plan SOAPIE: Subjective, objective, assessment, plan, intervention, evaluation PIE: Problem, intervention, evaluation Focus Charting (DAR): Data, action, response Methods of Reporting 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 Common Record-Keeping Forms Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. Nurses need to document all their services for payment. Long-Term Health Care Documentation Governmental agencies are instrumental in determining the standards and policiesfor documentation. The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaidlegislation for long-term care documentation.The department of health in states governs the frequency of written nursing records Computerized Documentation 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. Reporting Change of shift Telephone reports Verbal or telephone orders Transfer reports Incident