Learning Objectives
By the end of this section, you will be able to:
- Identify reasons that accurate health records are important
- Define and understand the important terms related to health records used in the healthcare industry
- Apply legal and ethical issues related to the health record
Nurses perform assessments to make professional judgments for the care of patients. The data collected during these assessments are recorded in a patient’s health record. A health record is a collection of subjective and objective clinical information pertaining to a patient’s physical and mental health, compiled from a variety of sources. The first stage of data collection is crucial to the proper execution of the remaining phases in the nursing process (Table 4.1).
| I. Assessment | Collecting subjective and objective data and documenting in the health record |
| II. Diagnosis | Analyzing data to make and prioritize professional clinical judgments |
| III. Outcome Identification | Using the previous information to effectively predict outcomes |
| IV. Planning | Developing solutions, developing a care plan, and prioritizing outcomes |
| V. Implementation | Completing the planned interventions |
| VI. Evaluation | Assessing whether outcomes have been met and revising as needed |
According to the American Association of Colleges of Nursing’s (AACN) The Essentials: Core Competencies for Professional Nursing Education, when nurses complete health assessments, they are doing more than just collecting information. Nurses use knowledge and comprehension to effectively analyze the data collected, and they then successfully apply clinical reasoning and improve patient care outcomes (AACN, 2021).
The Importance of an Accurate Health Record
A patient’s health record includes previous and current information related to medications, treatments, tests, immunizations, surgeries, hospitalizations, and notes from visits to healthcare providers. Each healthcare organization has specific policies and procedures that detail the nurse’s responsibilities regarding how and where to document. Health care’s oldest and largest accrediting organization, The Joint Commission, recommends that all data related to the patient’s assessment, diagnosis, care plan, and outcomes are collected and stored in the patient record (The Joint Commission, 2021). It is important that all information in a patient’s health record is accurate. If the health record is inadequate or erroneous, a provider may make an incorrect clinical judgment that could adversely affect continuity of care and result in poor patient outcomes.
In health care, continuity of care is the process of delivering quality care by a coordinated provider-led medical team with the common goal of positive patient outcomes. The coordination of care among team members can occur with proper exchange of patient information across an interlinked healthcare system that allows for all stakeholders to have access to the same information. Accurate patient health information allows for the continuity of care. Nurses are often responsible for obtaining the health history information as part of the initial admission assessment. Throughout the patient’s plan of care, interdisciplinary team members will often add information to the patients’ health record (Figure 4.2), building on the foundation developed by the nurse.
A health history begins with determining the patient’s chief complaint or reason for seeking medical care. Nurses begin the assessment by asking a set of standard questions (discussed in 4.2 Data Collection and Documentation) and then documenting the patient’s response, either on preprinted forms or in the EHR. Data collected are legally protected and can be used in court proceedings at any time and therefore must be accurate. Obtaining a valid and detailed health history requires effective communication and interviewing skills, which are discussed in 3.2 Comprehensive Interview Practices.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Patient-Centered Care
Definition: Recognize the patient or designee as the source of information and a full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs. The nurse will:
- Discuss principles of effective communication.
- Describe basic principles of consensus building and conflict resolution.
- Examine nursing roles in assuring coordination, integration, and continuity of care.
Let’s take these QSEN Clinical Competencies and incorporate them into a patient care scenario. You are assigned a patient on the postsurgical recovery floor. During report, you learn your patient, Mr. Smith, a 66-year-old male, had open abdominal surgery thirty-six hours ago for gallbladder removal and a mesh hernia repair. He is due to be transferred to the medical-surgical (med-surg) floor later this afternoon. The nurse giving report also states the patient has some visitors at the bedside, and they have been here a few hours. Upon entering the room, you notice that the patient is in bed, clutching a pillow over his abdomen and has facial grimacing. There are several people standing around the bed visiting with the patient, including his wife.
Assess:
Step 1: You walk in and introduce yourself to the patient. You ask the visitors to step out so you can assess Mr. Smith, and his wife interrupts you and speaks up saying, “Oh no they can stay, they are family and have just flown in this morning. We want them here.”
You proceed to inform Mr. Smith you need to complete an assessment and would prefer to respect his privacy by having everyone step out for a few minutes. Mr. Smith’s wife speaks up again and says, “They are not leaving, you can assess him with us here, just like all the other nurses have.” Mr. Smith nods his head “yes” and says, “Please go ahead and do whatever you need to.”
Step 2: You collect Mr. Smith’s vital signs and notice that his blood pressure, respirations, and heart rate are higher than previous readings. You ask Mr. Smith to rate his pain level. As he starts to answer, his wife says, “Remember honey, with a pain level below three, you can get transferred to med-surg”, then she proceeds to tell the visitors how much nicer the rooms are on the med-surg floor. Mr. Smith states, “My pain is two out of ten”; he has pursed lip breathing and has facial grimacing.
Diagnosis/Plan:
Step 3: Incorporating the knowledge you have regarding QSEN’s Clinical Competency: Patient-Centered Care, what is your next step?
After reflecting, analyzing the situation, and thinking about consensus building, conflict resolution, and using the patient as your primary source of information, you make a decision.
Implementation:
Step 4: You tell the visitors and the patient’s wife, “I must now insist you all step out for just a moment so I can complete a proper assessment.” You explain that you need to expose Mr. Smith’s abdominal area, and out of respect for his privacy, they really need to leave the room. You suggest they go get a cup of coffee or relax in the visitors’ lounge for just a little while. The patient’s wife and visitors reluctantly leave the room.
Assess: Note the nursing process is fluid, and previous steps can be revisited if needed.
Step 5: You reassess Mr. Smith’s vital signs, and they remain elevated.
- Blood pressure (B/P) 146/92
- Heart rate (HR) 117
- Respirations 28
- Temperature 98.4°F (oral)
You ask for his pain level again, and Mr. Smith starts to become tearful. He explains that his pain is really at an eight out of ten, but he does not want to disappoint his wife. She has been looking forward to being transferred to a bigger room, one with a bed she can sleep in, instead of a pull-out recliner. You assess Mr. Smith’s incision, and the incision is well-approximated, no signs of drainage, and sutures are intact. His skin is not hot to touch and shows no signs of infection.
Diagnosis/Outcome Identification and Planning:
Step 6:
Based on collected clinical data, and the incorporation of patient-centered care, you determine Mr. Smith is experiencing pain, anxiety, and fear. Your chosen nursing diagnoses are as follows:
- Pain related to recent surgical incision as evidenced by grimacing, expression of pain, and guarding behavior
Intervention: Provide the patient pain medication as ordered.
- Anxiety related to increased pain as evidenced by apprehension to report pain, verbalization of stress and fear
Intervention: Provide patient education regarding pain’s correlation to decreased healing. Provide education about the importance of seeking assistance when needed.
- Ineffective coping related to not reporting pain when assessed, not incorporating coping techniques, and inability to express feelings
Intervention: Teach the patient coping techniques such as guided imagery, reducing environmental stimuli, repositioning, and increasing mobility.
- Knowledge deficit: hospital policies related to lack of knowledge regarding pain and transfer to lower-acuity care floor
Intervention: Provide patient education regarding hospital policies and transfers. Explain that a transfer to medical-surgical floor is not just based on reports of pain but also based on a patient’s needed level of care and recovery status post-surgery.
Implementation:
Step 7: You educate Mr. Smith that pain is an expected part of recovery; because of this, the provider has ordered as-needed pain medication to provide relief. You explain to Mr. Smith how suffering from pain can hinder healing, and there is no need to suffer. You ask Mr. Smith if he would like something to relieve his pain. He says “Yes, please!” Then you explain he has the following order:
- mild pain: acetaminophen 500 mg, 2 tablets PO Q6 hours PRN
- moderate pain: hydrocodone bitartrate and acetaminophen tablets, USP 5 mg/500 mg, 2 tablets PO Q6 hours PRN
- severe pain: morphine sulfate, 2 mg IV Q4 hours PRN
You provide education on the different medications and severity scales, then medicate according to provider orders and teach coping techniques to help Mr. Smith manage any future pain and keep it at a manageable level. You explain the hospital policy on transfer to other floors and how he does not need to be concerned with the criteria of transfer because that is the administration’s job. You state his job is concentrating on his recovery. You educate on patient-centered care and how he is considered a valuable member of the care management team.
Evaluation:
Step 8: After giving Mr. Smith time for pain medication to take effect, you return to his room and reassess. Upon entering the room, you notice the lights and TV are off, and he is alone. Mr. Smith states his pain level is at a zero out of ten, and he was finally resting comfortably. He said he asked his family to take his wife home for some well-deserved relaxation time, which in return allowed him to get some too. Mr. Smith then proceeded to thank you for alleviating his fears and encouraging him to focus on recovery.
Types of Health Records
The health record can be in paper format using preformatted templates or in a digital format. Although once the primary method, paper records are no longer preferred for patient records, as they can be a barrier to effective communication among stakeholders due to lack of accessibility across multiple locations. Paper-based charting also does not meet current privacy standards for protecting a patient’s health information. To promote patient-centered care, the American Recovery and Reinvestment Act of 2009 (ARRA) was developed. This was the first big push for healthcare institutions to switch from paper-based records to an EHR system. The electronic health record (EHR) is a digital format of a patient’s chart that contains data related to the patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results. In April 2018, the Centers for Medicare and Medicaid Services (CMS) changed the name of the Medicare and Medicaid EHR Incentive Programs to the Medicare Promoting Interoperability Program to “focus on interoperability and improving patient access to health information” (CMS, 2018).
To be in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and demonstrate meaningful use, a nationwide transition to EHRs was initiated. During this transition, many people use the terms electronic medical record and EHR interchangeably, but they do represent different records. An electronic medical record (EMR) is the digital version of a patient’s chart at any one practice. An EMR contains the patient’s history with a specific provider, diagnoses, and treatments prescribed by all the providers of that practice. The EMR stays at that facility; it is not designed to be shared or transferred to other facilities (think Medical: stays at the medical office). The EHR, on the other hand, is more of a snapshot of the patient’s entire medical history. The purpose of the EHR is to enable multiple healthcare professionals across different platforms to easily view the patient’s health history, risks, health promotion, education, and actual long-term care issues (think Health: involves a team of professionals).
Unfolding Case Study
Unfolding Case Study #1: Part 4
Refer to Chapter 3 Patient Communication and Interviewing for Unfolding Case Study Parts 1 to 3 to review the patient data. The nurse is providing care to a 28-year-old female patient who arrived at the walk-in medical clinic. The female patient speaks only Spanish and is accompanied by her bilingual, 10-year-old son. Following the initial assessment, the patient’s respiratory status begins to rapidly decline.
| Past Medical History | Patient is a mother of one, who cares for her child and mother in a small apartment. The patient's mother is homebound and is not present at appointment. Patient cleans houses to support her family, but income is inconsistent. Patient has an eighth-grade education and speaks no English. Medical history includes seasonal allergies, sinusitis, and two episodes of COVID-19 in the past two years. Family history: Patient’s father is deceased, and patient’s mother has Alzheimer disease, stage II. Patient’s son is in good health, talkative, and attentive to his mother. Social history: Patient is primary caregiver for mother and adolescent. No other support systems available. Patient has difficulty shopping and making doctor’s appointments due to lack of care for mother. Patient has difficulty communicating in English, but son translates for his mother. No current medications and no known allergies. |
| Nursing Notes | 2100: Assessment Medical translator is present to assist with nurse and patient communication. Patient has become increasingly short of breath with conversation and appears to be in distress. Oxygen continues per nasal cannula at 2 L/min. Patient’s son has become anxious and distraught at the decline in his mother’s appearance. Son is asking many questions and has begun to cry. Son states that he wants to read his mother’s medical records so that he can understand what is going on and explain it to her. |
| Flow Chart | 2130: Assessment Blood pressure: 150/92 mm Hg Heart rate: 115 beats/minute Respiratory rate: 28 breaths/minute Temperature: 102.1°F (37.2°C) Oxygen saturation: 89 percent on 2 L nasal cannula Pain: 9/10–ear |
| Lab Results | None |
| Diagnostic Tests/Imaging Results | Chest x-ray: bilateral infiltrates indicative of pneumonia Sputum culture pending |
| Provider’s Orders | Transfer patient to nearest hospital for admission. |
Terms Used in Health Information
The type of data collected will determine where it is recorded in the EHR (Figure 4.3). Every healthcare facility has a policy that outlines the minimum data set (MDS), which is the mandatory information that must be collected from every patient. MDS is mandated by CMS for long-term care and used as a quality measurement tool for care provided.
When a nurse performs an initial health assessment, which is the systematic and purposeful collection and analysis of patient information, it begins with an accurate health history. The different types of nursing assessments are discussed further in 4.2 Data Collection and Documentation. Once data are recorded, a health information exchange (HIE) can take place. HIE provides a vehicle for doctors, nurses, patients, and other interdisciplinary healthcare members to access and share critical healthcare information in a secure electronic platform with the goal of improving patient care. EHRs offer interoperability, or the ability to share patient information across multiple healthcare systems in digital format.
Legal and Ethical Issues Related to the Health Record
When collecting the patient’s data, you are also responsible for safeguarding and keeping the information confidential. The Health Insurance Portability and Accountability Act (HIPAA) is a law that details national standards for sharing of information in the EHR and protection of privacy for health information (HHS, 1996). Legally and ethically, the patient has the right to privacy concerning their medical information. HIPAA regulations state that a healthcare facility may release protected health information without written consent in certain situations, such as the investigation and prosecution of a crime, public health and emergencies, research, judicial and administrative proceedings, and quality improvement, licensing, and regulation. While EHRs allow all healthcare professionals to easily access a patient’s information from a variety of locations, many employers monitor and may even limit employee access to only those who have a need to know in order to complete their job. Most healthcare entities have policies and procedures in place regarding accessing a patient’s information because electronic records are traceable, and all actions are discoverable. For instance, looking up a neighbor’s or friend’s information without being part of that person’s healthcare team could result in serious consequences including termination and financial penalties.
During the initial assessment and collection of health history information, the nurse explains legal and ethical components of care. The patient is asked to sign consent forms allowing the facility to treat and provide medical care. The patient will also give consent to allow their information to be shared among healthcare entities such as pharmacies, insurance companies, and government organizations that will have financial responsibility for the medical costs, such as Medicare. Patients are asked if they have legal documents that dictate their preferred care, such as a living will or power of attorney. An advance directive contains the patient’s wishes regarding life-sustaining medical treatments, and a medical power of attorney outlines who can make medical decisions on behalf of the patient in the event they cannot do so themselves. Last, all healthcare facilities have some form of the Patient Care Partnership (formerly titled a Patient Bill of Rights). This document informs the patient what to expect while receiving medical care under the organization and outlines their rights, such as the right to information, the right to privacy, and the right to accommodation of needs. The age of the patient will also determine if the nurse can collect data from the patient or if it must be from the parent or legal guardian. The age of majority is defined by each U.S. state as the age at which one can make their own decisions, including healthcare decisions.
The EHR is the nurse’s best form of evidence detailing interactions with a patient. You have probably heard the saying, “If it is not documented, it did not happen,” countless times as a nursing student (Ethicist, 2016). This is because attorneys consider the EHRs the most reliable and accurate representation of the patient care provided. EHRs can be subpoena duces tecum, or court ordered to be produced, years after the initial encounter took place. If pertinent information in the health history is overlooked and not documented, the nurse could be held liable if the patient has a poor outcome. Legal representatives can use incomplete documentation to prove care was not provided.
Ownership of the Health Record
Patients, physicians, nurses, and the entire healthcare team all have vested interests in the information within an EHR. However, there seems to be uncertainty at times regarding who actually owns the information. Many patients feel as if they do, seeing as the information is about them. Many healthcare organizations believe they do, because if it were not for them collecting, organizing, and utilizing the data, EHR would not exist. According to EHR communication guidelines, within U.S. states that fall under federal guidelines, the medical records belong to the provider, practice, or facility that created the record (Office of the National Coordinator for Health Information Technology [ONC], 2018). However, the information in the medical records belongs to the patient. Once the consent forms are signed, the patient can request access, usually required in writing.
Link to Learning
The American Nurses Association developed a checklist for streamlining documentation. Nurses can review the PDF for tips on how to document according to current practice standards and reduce errors. the document Principles for Nursing Documentation: Guidance for Registered Nurses can help save time spent documenting and increase time spent with patients.
Nurse’s Role in Maintaining Accurate Health Record
The nurse’s role is to provide quality clinical care based on the foundation of healing. Effective communication among healthcare providers is an essential component in providing quality patient care. As you begin documenting the patient’s health history, start looking for links, patterns, and connection of information that might otherwise be missed. Accurate recordkeeping is beneficial not only to the patient but to the entire healthcare team. It is important that difficulties the patient is having are documented, as well as what is or has been done to overcome these issues. For instance, if a particular intervention or medication has been ineffective in the past for the same condition, like a patient with a history of ear infections and multiple attempts of a particular antibiotic not being effective, then the patient should not have to repeat the same intervention again. Repeating unsuccessful interventions wastes time and money and diminishes the patient’s trust in the healthcare team.
Unfolding Case Study
Unfolding Case Study #1: Part 5
Refer back to Unfolding Case Study #1: Part 4 to review the patient data.
| Nursing Notes | 2300: Assessment Patient appears to be sleeping after first dose of IV antibiotics. Steroid injection administered, and coughing episodes have decreased. Oxygen per nasal cannula at 2 L/min. Social service referral made to address care and safety of minor child and dependent relative in the home. Transportation to hospital has been delayed due to tornado warning and storms in the area. |
| Provider’s Orders | Close observation Administer IV antibiotic and steroid injection Prepare for transport to hospital |
| Nursing Assessment | 2330: Assessment Patient’s son stepped into hallway of clinic, asking for a nurse. During physical assessment, rash noted on patient’s face with redness and facial edema, swelling of the tongue and throat, temperature of 100.5°F, irritability, and oxygen saturation of 96 percent. |
According to the American Journal of Medicine, the nurse spends more time with the patient than any other health-care member (Butler et al., 2018). Nurses know that spending time with the patient is one way to uncover important health information that might not otherwise come up. The American Nurses Association lists patient advocacy as the “pillar of nursing” and considers it to be one of the most substantial reasons nurses are essential members of the healthcare team (ANA, 2021). Completing an accurate health history and maintaining updates on any changes displays patient advocacy. The nurse also demonstrates being a patient advocate by maintaining confidentiality of the information in the health record.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Patient-Centered Care
Traditionally, documentation consists of timely and accurate charting. However, the QSEN-updated definition is expanded and calls for using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.
Creating and maintaining an accurate EHR takes time, but the time nurses spend documenting may come at the expense of providing safe, quality patient care. In an effort to help alleviate nursing concerns related to the time spent documenting, an evidence-based tool is used to help streamline documentation.
Unfolding Case Study
Unfolding Case Study #1: Part 6
Refer back to Unfolding Case Study #1: Part 5 to review the patient data.
| Nursing Notes | 2400: Assessment Physical examination: HEENT: Pupils equal, reactive to light, and accommodating (PERRLA), mucus membranes moist, pharynx without lesions, palate intact. No thyroid enlargement. Tongue swelling present. Respiratory: Course crackles in lower lobes auscultated bilaterally. Cardiovascular: Sinus tachycardia, no edema, peripheral pulses 2+. Abdomen: Bowel sounds present in all four quadrants, no tenderness noted. Musculoskeletal: No bone or joint pain reported, patient has full range of motion. Skin: Pale and dry, no bruising, facial rash subsiding. Mental assessment: Patient is lethargic but responding appropriately with help from interpreter. |
| Flow Chart | 0100: Assessment Blood pressure: 140/82 mm Hg Heart rate: 105 beats/minute Respiratory rate: 24 breaths/minute Temperature: 100.1°F Oxygen saturation: 96 percent on 2 L nasal cannula |
| Provider’s Orders | Diphenhydramine (Benadryl) 25 mg/min IV Q4 PRN for allergic reaction Close observation until discharge to hospital. |