lOMoARcPSD|25973474
15 Documenting and Reporting
Nursing (AMA Computer University)
, lOMoARcPSD|25973474
Kozier & Erb's
Fundamentals of Nursing
Concepts, Process, and Practice
TENTH EDITION, GLOBAL EDITION
15 Documenting and Reporting
LEARNING OUTCOMES
1. List the measures used to maintain confidentiality and security of computerized client records.
2. Discuss purposes for client records.
3. Compare and contrast different documentation methods:
source-oriented and problem-oriented medical records, PIE,
focus charting, charting by exception, computerized
records, and the case management model.
4. Explain how various forms in the client record (e.g., critical
pathways care plans, Kardexes, flow sheets, progress notes,
discharge/transfer forms) are used to document steps of the
nursing process (assessing, diagnosing, planning, implementing, and evaluating).
5. Compare and contrast the documentation needed for clients
in acute care, long-term care, and home health care settings.
6. Discuss guidelines for effective recording that meet legal
and ethical standards.
7. Identify prohibited abbreviations, acronyms, and symbols
that cannot be used in any form of clinical documentation.
8. Identify essential guidelines for reporting client data.
1. Measures used to maintain confidentiality and security of computerized client records include:
- Access controls: Access to electronic health records (EHRs) should be restricted to authorized
individuals through the use of unique usernames and passwords, biometric identification, or smart card
authentication. Access levels should be based on the principle of least privilege, which means that
individuals should only have access to the information necessary to perform their job duties.
- Encryption: Electronic records should be encrypted to prevent unauthorized access or disclosure
during transmission or storage. Encryption can be used to protect data at rest (stored on servers or hard
drives) and data in transit (transmitted over networks).
- Audit trails: Audit trails record all access to electronic records, including who accessed the record,
when, and what changes were made. Audit trails help to identify unauthorized access or disclosure
of client information.
- Backup and recovery: Electronic records should be regularly backed up to prevent data loss in the
event of a system failure or other disaster. Backup data should be stored in a secure location and
tested regularly to ensure that it can be recovered if needed.
2. Purposes for client records include:
- Communication: Client records provide a means of communication among healthcare providers,
ensuring that all members of the care team are informed about the client's condition, treatment plan,
and progress.
- Legal and regulatory requirements: Healthcare organizations are required to maintain client records to
comply with legal and regulatory requirements, including medical malpractice liability, accreditation
standards, and government regulations.
- Quality improvement: Client records can be used to evaluate the quality of care provided, identify
areas for improvement, and monitor the effectiveness of interventions.
- Research: Client records can be used for research purposes, including epidemiological studies,
clinical trials, and outcomes research.
- Reimbursement: Client records are used to support reimbursement claims from insurance
companies and government payers, providing documentation of the care provided and the client's
medical necessity for services.
15 Documenting and Reporting
Nursing (AMA Computer University)
, lOMoARcPSD|25973474
Kozier & Erb's
Fundamentals of Nursing
Concepts, Process, and Practice
TENTH EDITION, GLOBAL EDITION
15 Documenting and Reporting
LEARNING OUTCOMES
1. List the measures used to maintain confidentiality and security of computerized client records.
2. Discuss purposes for client records.
3. Compare and contrast different documentation methods:
source-oriented and problem-oriented medical records, PIE,
focus charting, charting by exception, computerized
records, and the case management model.
4. Explain how various forms in the client record (e.g., critical
pathways care plans, Kardexes, flow sheets, progress notes,
discharge/transfer forms) are used to document steps of the
nursing process (assessing, diagnosing, planning, implementing, and evaluating).
5. Compare and contrast the documentation needed for clients
in acute care, long-term care, and home health care settings.
6. Discuss guidelines for effective recording that meet legal
and ethical standards.
7. Identify prohibited abbreviations, acronyms, and symbols
that cannot be used in any form of clinical documentation.
8. Identify essential guidelines for reporting client data.
1. Measures used to maintain confidentiality and security of computerized client records include:
- Access controls: Access to electronic health records (EHRs) should be restricted to authorized
individuals through the use of unique usernames and passwords, biometric identification, or smart card
authentication. Access levels should be based on the principle of least privilege, which means that
individuals should only have access to the information necessary to perform their job duties.
- Encryption: Electronic records should be encrypted to prevent unauthorized access or disclosure
during transmission or storage. Encryption can be used to protect data at rest (stored on servers or hard
drives) and data in transit (transmitted over networks).
- Audit trails: Audit trails record all access to electronic records, including who accessed the record,
when, and what changes were made. Audit trails help to identify unauthorized access or disclosure
of client information.
- Backup and recovery: Electronic records should be regularly backed up to prevent data loss in the
event of a system failure or other disaster. Backup data should be stored in a secure location and
tested regularly to ensure that it can be recovered if needed.
2. Purposes for client records include:
- Communication: Client records provide a means of communication among healthcare providers,
ensuring that all members of the care team are informed about the client's condition, treatment plan,
and progress.
- Legal and regulatory requirements: Healthcare organizations are required to maintain client records to
comply with legal and regulatory requirements, including medical malpractice liability, accreditation
standards, and government regulations.
- Quality improvement: Client records can be used to evaluate the quality of care provided, identify
areas for improvement, and monitor the effectiveness of interventions.
- Research: Client records can be used for research purposes, including epidemiological studies,
clinical trials, and outcomes research.
- Reimbursement: Client records are used to support reimbursement claims from insurance
companies and government payers, providing documentation of the care provided and the client's
medical necessity for services.
