Hi, let's talk about documentation and informatics.
Sounds pretty blah, right?
But we're gonna explore why documentation is so
very important for patient care, the health care system,
and explore the methods in which we document.
Okay, so as nurses, we document and
obtain information as do healthcare providers.
This information is called PHI,
or protected health information.
So this info is important in communicating care
needs, patient events, and treatment of the patient.
So other PHI we consider are patient's social security numbers,
demographic information, diagnosis and treatment information.
So therefore, nurses are legal and ethically responsible
for protecting the information from all unauthorized users.
So this slide is very important, so let's talk about this.
So in '96, this act was established in law to which
protects patient health information for patient privacy.
We call it HIPAA.
All right, nursing students pay attention
to this case, you're gonna hear this a lot.
Your clinical instructor especially
is gonna talk about HIPAA to you.
So HIPAA stands for Health Insurance, Portability
and Accountability Act, otherwise known as HIPAA.
All right, this requires that disclosure of health
information are limited to the minimum necessary.
So what that means is, disclosed
to those involved in patient care only.
So if you remember, we have a legal and
an ethical responsibility to protect this PHI.
Alright, so let's talk about
what happens if we violate this.
This is something that we can report to our agency's compliance
officer, and we may or may not have some disciplinary action.
But again, just additional training may be needed.
So don't sweat it, just be honest, report it to your
agency's compliance officer, and they will take it from there.
All right, so particularly nursing students,
or just nurses or anyone in the healthcare.
Let's talk about what violations of HIPAA may look like.
So this may look like discussing patient information
at maybe the elevators or while you're eating lunch.
This could be anything in regards to
giving information to unauthorized individuals.
Here's the other thing, looking at chart information,
when you're not involved in that patient care.
Here's a prime example.
Maybe you're a patient at a certain
agency, you have access to those records.
You cannot look up your own records
because you are not involved in that care.
That's just one instance.
The other thing I tend to tell nursing
students is not disposing of PHI properly.
So case in point is maybe the nurse runs
off lab information for that nursing student.
That nursing student is not allowed to
take that information out of the hospital.
It must be shredded in the proper receptacle.
Okay, so we talked about some minor violations.
What about big violations?
So if you do violate HIPAA with a criminal
intent, this could mean fine or even imprisonment.
And when we're talking about
fines, we're talking about big ones.
So what's the exception to this law?
The exception to know is as health care providers,
if in our patients, we ever expect abuse, neglect,
or maybe even domestic violence with our
patients, this is the exception to violate HIPAA.
Okay, so now we know to keep this information safe.
But what is the purpose of patient information?
So one of those is communication.
Those records can be used to communicate patient
treatment, lab results, and even physician orders.
So next, let's talk about legal
documentation for purpose of medical record.
This proves what we did for our
patients while they were under our care.
As you can imagine, errors and
poor patient outcomes can occur.
Therefore documentation is
essential and may need to be reviewed.
Next thing a lot of us as nurses and maybe even
nursing students don't think about is reimbursement
using the medical record for that purpose.
So much of the information found in the chart that's
documented by the nurse and the healthcare provider
is what is reviewed for healthcare reimbursement.
This may be reimbursed by your
health insurer, or government agency.
So next, let's talk about education.
This can be used with a medical record as an
educational tool for exposure to documentation,
looking at patient treatment plans to further
quality patient care and patient cases to be reviewed.
Research is at the forefront of what we do.
So medical records can also be used as a tool.
Patient information from several
different cases can be reviewed.
This can help us improve those patient
outcomes and even create new research needs.
Lastly, let's look at medical records for auditing purposes.
Patients with certain diagnosis or treatments can
be evaluated to see if certain standards are being met.