Transcript Patient Safety, Communication and Recordkeeping/ HIPAA

Patient Safety,
Communication and
Recordkeeping/
HIPAA
Objectives
1. Describe Patient Safety issues
2. Describe the rationale for documenting
respiratory care activities.
3. List the elements of a patient medical record.
4. Identify five medical record documentation
standards.
5. List respiratory care information commonly
recorded in the medical record.
Objectives
6. Describe the rationale for the electronic medical record.
7. Define the concept of patient confidentiality.
8. Discuss things that the respiratory therapist can do to improve
patient safety.
9. Discuss SBAR communication.
Patient Safety
• Quality care is vital as is patient safety.
• Aspects of patient safety include:
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Infection control/contamination control
Risk of falls
Risk of aspiration
Medication and surgical mistakes
Wrong patient/identification mistakes
Medical equipment failure/mismanagement
Patient Safety
• Medical errors have been implicated in the
premature deaths of 98,000 patients per
year, accounting for between $17 and $29
billion in costs annually.
We know that patient safety is the
bedrock of quality care
Institute of Medicine: Quality Care
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IOM elements of “Quality”
• Safe: avoiding injuries to patients from the care that is intended to help
them
• Timely: reducing waits and sometimes harmful delays for both those who
receive and those who give care
• Effective: providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit
(avoiding underuse and overuse)
• Efficient: avoiding waste, in particular waste of equipment, supplies, ideas,
and energy
• Equitable: providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and
socioeconomic status
• Patient-Centered: providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions
“STEEEP” Framework outlined by the Institute of Medicine (“IOM”)
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We preach “quality” but can we say
we have a true “culture of safety”
• Culture
• “The way we do things around here”
• Safety
• Avoiding injuries from care intended to help patients
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Types of error
• About half of the adverse events occurring
among inpatients resulted from surgery.
• Others
• Complications from drug treatment
• therapeutic mishaps
• diagnostic errors were the most common nonoperative events.
Types of error
• Cognitive errors--such as incorrect
diagnosis or choosing the wrong
medication-- more likely to have been
preventable and more likely to result
in permanent disability than technical
errors.
Which patients are most at risk?
• Those undergoing cardiothoracic surgery,
vascular surgery, or neurosurgery
• Those with complex conditions
• Those in the emergency room
• Those looked after by inexperienced
doctors
• Older patients
How dangerous is health
care?
• Less than one death per 100 000 encounters
• Nuclear power
• European railroads
• Scheduled airlines
• One death in less than 100 000 but more than 1000 encounters
• Driving
• Chemical manufacturing
• More than one death per 1000 encounters
• Bungee jumping
• Mountain climbing
• Health care
Why do errors happen?
• All humans make errors: indeed, “the ability to
make mistakes” allows human beings to function
• Most of medicine is complex and uncertain
• Most errors result from “the system”--inadequate
training, long hours, ampoules that look the same,
lack of checks, etc
• Healthcare has not tried to make itself safe
• FUTURE: More accountability, hospital fines/costly
lawsuits, readmission penalties…
Medical Information
Management
• Documentation provides:
oA reference on the status of the patient’s
condition prior to intervention
oA record of key steps with the provision of care
oAn account of the effectiveness of care
oAn opportunity to record recommendations or
modifications to the care
oA record of the educational materials provided
to the patient
oOngoing needs and the discharge plan
Electronic Medical or Health
Records
• Electronic medical record (EMR) and electronic health
record (EHR) are two terms to describe computerized
systems that track and record patient information
electronically.
• The EMR/EHR:
o Speeds entry
o Improves the storage and retrieval of patient information
o Improves the provision of care
o Is designed to guide the clinician through an activity from
start to finish
o Incorporates data that are critical to the provision or
evaluation of response to care
Electronic Medical or Health
Records
• Drop-down lists help limit errors in data entry, provide consistency,
and speed up the selection process.
• Hard stops require the therapist to enter data or complete the
required field selection prior to progressing or committing the
record to the EMR.
• An electronic signature is a method to allow practitioners to sign off
on care rendered.
The Patient’s Medical Record
Medical Record – “Chart”
A documented account of the occurrences pertaining
to the patient throughout his or her stay in a healthcare
institution
The Patient’s Medical Record
Medical Record – “Chart”
It is the property of the institution and its contents
are confidential and may not be read or discussed by
anyone except those directly caring for the patient in a
hospital or medical care facility.
The Patient’s Medical Record
Medical Record – “Chart”
It is a legal document and must be maintained by the
healthcare institution for days, months, or years, in case it
is needed in a court of law
The Patient’s Medical Record
Components of the Medical Record
• Admission Sheet
• Records pertinent patient information (e.g., name, address,
religion, nearest of kin), admitting physician, and admission
diagnosis
• History and Physical
• Records the patient’s admitting history and physical
examination as performed by the attending physician or
resident
The Patient’s Medical Record
Components of the Medical Record
• Physician’s Orders
• Records the physician’s orders and prescriptions
• Progress Sheet
• Commonly referred to as “progress notes”
• Keep a continuing account of the patient’s progress for the
physician
The Patient’s Medical Record
Components of the Medical Record
• Nurses’ Notes
• Describes the nursing care given to the patient, including the
patient’s complaints (subjective symptoms), the nurses’
observations (objective signs), and the patient’s response to
therapy
• Medication Admission Record “MAR”
• Notes drugs and IV fluids that are given to the patient
The Patient’s Medical Record
Components of the Medical Record
• Vital Signs Graphic Sheet
• Records the patient’s temperature, pulse, respiration, and
blood pressure over time
• I/O Sheet
• Records the patient’s fluid intake (I) and output (O) over time
The Patient’s Medical Record
Components of the Medical Record
• Laboratory Sheet
• Summarizes the results of laboratory tests
• Consultation Sheet
• Records notes by specialty physicians who are called in to
examine a patient to make a diagnosis
The Patient’s Medical Record
Components of the Medical Record
• Surgical or Treatment Consent
• Records the patient’s authorization for surgery or treatment
• Anesthesia and Surgical Record
• Notes key events before, during, and immediately after surgery
The Patient’s Medical Record
Components of the Medical Record
• Specialized Therapy Records
• Records specialized treatments or treatment plans and patient
progress for various specialized therapeutic services (e.g.,
respiratory care, physical therapy)
• Specialized Flow Sheets
• Records measurements made over time during specialized
procedures (e.g., mechanical ventilation, kidney dialysis)
Flow Sheets
The Patient’s Medical Record
Legal Aspects of Recordkeeping
• Legally, documentation of care given to a patient means
that care was given
• Legally, no documentation means that care was not
given
• Lack of documentation can be interpreted as patient neglect
The Patient’s Medical Record
General Rules for Medical Recordkeeping
• Entries should be printed or handwritten. After
completing the account, sign the chart with the initial of
first name, complete last name, and your title (CRT, RRT,
Resp Care Student, etc.)
Example:
B. Kind, RRT
• Do Not Use ditto marks – “ “
The Patient’s Medical Record
General Rules for Medical Recordkeeping
• Do not erase!
Erasures provide reason for questions if the chart is
used in a court of law.
If a mistake is made, a single line should be drawn
through the mistake and the word “error” printed
above it; the correction should be initialed
error
Example: Respiratory Tx given at 10:00
10:30
The Patient’s Medical Record
General Rules for Medical Recordkeeping
• Record after completing each task for the patient (never
beforehand) and sign your name correctly after each
entry
• Be exact in noting the time, effect, and results of all
treatments and procedures
• Describe clearly and concisely observations and
assessments, e.g., the character of breath sounds,
percussion notes, secretions, etc.
The Patient’s Medical Record
General Rules for Medical Recordkeeping
• Leave no blank lines in the charting
Draw a line through the center of an empty line or part
of a line. This prevents charting by someone else in an
area signed by you
• Use the present tense. Never use the future tense, as
in “Patient to receive treatment after lunch.”
The Patient’s Medical Record
General Rules for Medical Recordkeeping
• Spell correctly
If you are not sure about the spelling of a word, use a
dictionary and look it up
• Use standard, hospital-approved abbreviations
• Do not make up your own
The Patient’s Medical Record
The Problem-Oriented Medical Record
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A documentation format used by some healthcare
institutions
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POMR contains the following:
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2.
3.
4.
The Database
The Problem List
The Plan
The Progress Note
The Patient’s Medical Record
The Problem-Oriented Medical
Record
• The Database
• Routine information about the patient
• General health history
• Physical examination results
• Results of diagnostic tests
The Patient’s Medical Record
The Problem-Oriented Medical Record
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The Problem List
• A problem is something that interferes with a
patient’s physical or psychological health or ability
to function
• Problems are identified and listed, based on the
information provided by the database
• The problem list is dynamic; new problems are
added as they develop and others problems are
removed as they are resolved
The Patient’s Medical Record
The Problem-Oriented Medical Record
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The Progress Note
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Contain the findings (subjective and objective), assessment,
plans, and orders of the doctors, nurses, and other practitioners
involved in the care of the patient
• The format used in often referred to as
SOAP
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S – subjective
O – objective
A – assessment
P - plan
The Patient’s Medical Record
Charting Using the SOAP Format
• Subjective
Information obtained from the patient, his or her
relatives, or a similar source
• Objective
Information based on caregivers’ observations of the
patient, the physical examination, or diagnostic or
laboratory tests such as ABG or PFT
• Assessment
The analysis of the patient’s problem
• Plan
Action to be taken to resolve the problem
The Patient’s Medical Record
Example of SOAP Entry
Problem 1
Pneumonia
Subjective
“My chest hurts when I take a deep breath”
Objective
Awake; alert; oriented to time, place, and person;
sitting upright in bed with arms leaning over bedside
stand; pale, dry skin; respiration 22/min and shallow;
pulse 110 beats/min, regular but thready; blood
pressure 130/89 (sitting); temperature 101 F;
bronchial breath sounds in left bases - posteriorly,
occasionally expectorating small amounts of purulent
sputum
The Patient’s Medical Record
Example of SOAP Entry
Assessment
Pneumonia continues
Plan
Therapeutic: Assist with coughing and deep
breathing at least every 2 hours; postural drainage
and percussion every 4 hours; assist with
ambulation as per physician orders and patient
tolerance.
Diagnostic: Continue to monitor lung sounds before
and after each treatment.
Education: Teach to cough and deep breathe and
evaluate return demonstration
SOAP Form
Choose 3 of the National Patient Safety Goals below. And state one thing that the
Respiratory Therapist can do to meet the goals that you have chosen.
Appropriate Handling of
Patient Information
• Confidentiality is the right of an individual to have personal,
identifiable medical information kept private.
• The Health Insurance Portability and Accountability Act
(HIPAA) is a federal mandate that ensures patient
confidentiality.
• HIPAA provides a uniform set of guidelines that apply to all
providers and organizations.