Chapter 26 Objectives

Documentation and Informatics

Describe methods for interdisciplinary communication within the health care team. Identify purposes of a health care record. Discuss legal guidelines for documentation. Identify ways to maintain confidentiality of electronic and written records. Describe five quality guidelines for documentation and reporting. Discuss the relationship between documentation and financial reimbursement for health care. Describe the different methods used in record keeping. Discuss the advantages of standardized documentation forms. Identify elements to include when documenting a patient's discharge plan. Identify the important aspects of home care and long-term care documentation. Describe the purpose and content of a hand-off report. Explain when to take and how to verify telephone orders. Discuss the relationship between informatics and quality health care. Describe the advantages of a nursing information system. Identify ways to reduce data entry errors.

Key Terms Accreditation, p. 349 Acuity records, p. 356 Case management, p. 355 Charting by exception (CBE), p. 354 Clinical decision support system (CDSS), p. 360 Computerized provider order entry (CPOE), p. 361

Consultations, p. 349 Critical pathways, p. 355 DAR, p. 354 Diagnosis-related group (DRG), p. 350 Documentation, p. 348 Electronic health record (EHR), p. 353 Electronic medical record (EMR), p. 353 Firewall, p. 361 Flow sheets, p. 356 Focus charting, p. 354 Hand-off reports, p. 357 Health informatics, p. 359 Incident (occurrence) report, p. 358 Information technology (IT), p. 359 Kardex, p. 356 Nursing informatics, p. 359 PIE, p. 354 Problem-oriented medical record (POMR), p. 353 Referrals, p. 349 SOAP, p. 354 SOAPIE, p. 354 Source record, p. 354 Standardized care plans, p. 356 Variances, p. 355

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Audio Glossary Interactive Learning Activities Key Term Flashcards Content Updates

Documentation is anything written or printed on which you rely as record or proof of patient actions and activities. Documentation in a patient's medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve clinical data, maintain continuity of care, track patient outcomes, and reflect current standards of nursing practice. Information in the patient record provides a detailed account of the level of quality of care delivered to patients. Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors. There are several documentation systems for recording patient data. Regardless whether documentation is entered electronically or on paper, as a member of the health care team you communicate information about patients in an accurate, timely, and effective manner. The quality of patient care depends on your ability to communicate with other members of the health care team. All health care providers require the same information about patients to develop an organized, comprehensive plan of care. When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and often delays or omissions in therapy occur. The health care environment creates many challenges for accurately documenting and reporting the care delivered to patients. The quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the health care system, and legal guidelines make documentation and reporting an extremely important responsibility of a nurse. Whether the transfer of patient information occurs through verbal reports, written documents, or electronically, you need to follow basic principles to maintain confidentiality of information.

Confidentiality
Nurses are legally and ethically obligated to keep information about patients confidential. They may not discuss a patient's examination, observation, conversation, diagnosis, or treatment with other patients or staff not involved in the patient's care. Only staff directly involved in a patient's care have legitimate access to the records. Patients frequently request copies of their medical records, and they have the right to read them. Each institution has policies to control the manner for sharing records. In most situations patients are required to give written permission for release of medical information. Legislation to protect patient privacy for health information, the Health Insurance Portability and Accountability Act (HIPAA), governs all areas of patient information and management of that information. To eliminate barriers that could delay access to care, providers are required to notify patients of their privacy policy and make a reasonable effort to obtain written acknowledgment of this notification. HIPAA requires that disclosure or requests

regarding health information are limited to the minimum necessary. This includes only the specific information required for a particular purpose. For example, if you need a patient's home telephone number to reschedule an appointment, access to the medical records is limited solely to telephone information. Sometimes nurses use health care records for data gathering, research, or continuing education. As long as a nurse uses a record as specified and permission is granted, this is permitted. When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. You can review your patients medical records only for information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient's medical record and plan of care. You do not share this information with classmates (except for clinical conferences) and do not access the medical records of other patients on the unit. Access to electronic health records is traceable through user log-in information. Not only is it unethical to view medical records of other patients, but breaches of confidentiality can lead to disciplinary action by employers and dismissal from work or nursing school. To protect patient confidentiality, ensure that written or electronic materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information) and never print material from an electronic health record for personal use.

Standards
Within a health care organization there are standards that govern the type of information you document and for which you are accountable. Institutional standards or policies often dictate the frequency of documentation such as how often you record a nursing assessment or a patient's level of pain. Know the standards of your health care organization to ensure complete and accurate documentation. Nurses are expected to meet the standard of care for every nursing task they perform. Patient records can be used as evidence in a court of law if standards are not met (ANA, 2005). In addition, your documentation needs to conform to the standards of the National Committee for Quality Assurance (NCQA) and accrediting bodies such as The Joint Commission (TJC) to maintain institutional accreditation and minimize liability. Usually an organization incorporates accreditation standards into its policies and revises documentation forms to suit these standards. Current documentation standards require that all patients admitted to a health care facility have an assessment of physical, psychosocial, environmental, self-care, knowledge level, and discharge planning needs. TJC standards require that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning (TJC, 2011). Other standards such as HIPAA include those directed by state and federal regulatory agencies and are enforced through the Department of Justice and the Centers for Medicare and Medicaid Services (ANA, 2005).

Interdisciplinary Communication within the Health Care Team

Patient care requires effective communication among members of the health care team. Effective communication takes place along two approaches. A patient's record or chart is a

confidential, permanent legal documentation of information relevant to his or her health care. The record is a continuing account of the patient's health care status and is available to all members of the health care team. All records contain the following information: Patient identification and demographic data Informed consent for treatment and procedures Admission data Nursing diagnoses or problems and nursing or interdisciplinary care plan Record of nursing care treatment and evaluation Medical history Medical diagnoses Therapeutic orders Medical and health discipline progress notes Physical assessment findings Diagnostic study results Patient education Summary of operative procedures Discharge plan and summary Reports are oral, written, or audiotaped exchanges of information among caregivers. Common reports given by nurses include change-of-shift reports, telephone reports, hand-off reports, and incident reports. A health care provider calls a nursing unit to receive a verbal report on a patient's condition. The laboratory submits a written report providing the results of diagnostic tests and often notifies the nurse by telephone if results are critical. Team members communicate information through discussions or conferences. For example, a discharge planning conference involves members of all disciplines (e.g., nursing, social work, dietary, medicine, and physical therapy) who meet to discuss the patient's progress toward established discharge goals. Consultations are another form of discussion in which one professional caregiver gives formal advice about the care of a patient to another caregiver. For example, a nurse caring for a patient with a chronic wound consults with a wound care specialist. Nurses document referrals (an arrangement for services by another care provider), consultations, and conferences in a patient's permanent record to allow all caregivers to plan care accordingly.

Purposes of Records
The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring.

Communication
The patient's record is one way that health care team members communicate patient needs and progress, individual therapies, content of consultations, patient education, and discharge planning. The plan of care needs to be clear to anyone reading the chart (see Unit 3). The record is the most current and accurate continuous source of information about a patient's health care status. Information communicated in the patient's record allows health care providers to know a patient thoroughly, facilitating safe, effective, and timely patientcentered decisions. To enhance communication and promote safe patient care, you base communication on assessment findings and document patient information as you provide care (e.g., immediately after providing a nursing intervention or completing a patient assessment).

Legal Documentation
Accurate documentation is one of the best defenses for legal claims associated with nursing care (see Chapter 23). To limit nursing liability nursing documentation must indicate clearly that a patient received individualized, goal-directed nursing care based on the nursing assessment. The record must describe exactly what happened to a patient and follow agency standards. This is best achieved when you chart immediately after providing care. Even though nursing care may have been excellent, in a court of law care not documented is care not provided. Common charting mistakes that result in malpractice include: (1) failing to record pertinent health or drug information, (2) failing to record nursing actions, (3) failing to record that medications have been given, (4) failing to record drug reactions or changes in patients' conditions, (5) writing illegible or incomplete records, and (6) failing to document discontinued medications. Table 26-1 provides guidelines for legally sound documentation.

Reimbursement
Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care. A DRG is a classification based on patients medical diagnoses. Hospitals are reimbursed a predetermined dollar amount by Medicare for each DRG. Detailed recording establishes diagnoses for determining a DRG. Your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency. A medical record audit reviews financial charges used in the patient's care. Private insurance carriers and auditors from federal agencies review records to determine the

reimbursement that a patient or a health care agency receives. Accurate documentation of supplies and equipment used assists in accurate and timely reimbursement.

Education
A patient's record contains a variety of information, including diagnoses, signs and symptoms of disease, successful and unsuccessful therapies, diagnostic findings, and patient behaviors. One way to learn the nature of an illness and the individual patient's response to it is to read the patient care record. No two patients have identical records, but you can identify patterns of information in records of patients who have similar health problems. With this information you learn to anticipate the type of care required for a patient.

Research
After obtaining appropriate agency approvals, nurse researchers often use patients records for research studies to gather statistical data on the frequency of clinical disorders, complications, use of specific medical and nursing therapies, recovery from illness, and deaths. Researchers also use this information to investigate nursing interventions or health problems. For example, a nurse wants to compare a new method of pain control with a standard pain protocol using two groups of patients. The records provide data on the two types of interventions: the new method and the standard pain control. The nurse researcher collects data from the records that describe the type and dose of analgesic medications used, objective assessment data, and patients subjective reports of pain relief. The researcher then compares the findings to determine if the new method was more effective than the standard pain control protocol. Analysis of the data contributes to evidence-based nursing practice and quality health care (see Chapter 5).

Auditing and Monitoring

Hospitals establish quality improvement programs for conducting objective, ongoing reviews of patient care. Quality improvement programs keep nurses informed of standards of nursing practice to maintain excellence in nursing care. Accrediting agencies such as TJC (2011) require quality improvement programs and set standards for the information located in a patient's record, including indications that a plan of care is developed with the patient as a participant and that discharge planning and patient education have occurred. Institutions and accrediting groups establish standards for quality care. Nurses audit records throughout the year to determine the degree to which standards of care are met and identify areas needing improvement and staff development (see Chapter 5). Nurses share deficiencies identified during monitoring with all members of the nursing staff to make changes in policy or practice.

Guidelines for Quality Documentation and Reporting

High-quality documentation and reporting are necessary to enhance efficient, individualized patient care. Quality documentation and reporting have five important characteristics: they are factual, accurate, complete, current, and organized.

Factual
A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, B/P 80/50, patient diaphoretic, heart rate 102 and regular. Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of the details regarding the behaviors exhibited by a patient. Objective documentation includes observations of a patient's behaviors. For example, instead of documenting the patient seems anxious, provide objective signs of anxiety and document the patient's pulse rate is elevated at 110 beats/min, respiratory rate is slightly labored at 22 breaths/min, and the patient reports increased restlessness. The only subjective data included in the record are what the patient says. When recording subjective data, document the patient's exact words within quotation marks whenever possible. For example, when he or she exhibits anxiety, you record, Patient states, I feel very nervous. Include objective data to support subjective data so your charting is as descriptive as possible.

TABLE 26-1

Legal Guidelines for Recording

GUIDELINES RATIONALE CORRECT ACTION Do not erase, apply correction fluid, or scratch out errors made while recording. Charting becomes illegible: it appears as if you were attempting to hide information or deface a written record. Draw single line through error, write word error above it, and sign your name or initials and date it. Then record note correctly. Do not document retaliatory or critical comments about patient or care by other health care professionals. Do not enter personal opinions. Statements can be used as evidence for nonprofessional behavior or poor quality of care. Enter only objective and factual observations of patient's behavior; quote all patient comments. Correct all errors promptly.

Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence. Avoid rushing to complete charting; be sure that information is accurate and complete. Record all facts. Record must be accurate, factual, and objective. Be certain entry is factual and thorough. A person reading the documentation should be able to determine that patient had adequate care. Do not leave blank spaces in nurses notes. Another person can add incorrect information in space. Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your name at end. Record all written entries legibly and in black ink. Do not use felt-tip pens or erasable ink. Illegible entries can be misinterpreted, causing errors and lawsuits; ink from felt-tip pen smudges or runs when wet and may destroy documentation; erasures are not permitted in patient charting; black ink is more legible when records are photocopied or scanned. Never erase entries or use correction fluid and never use pencil. If an order is questioned, record that clarification was sought. If you perform order known to be incorrect, you are just as liable for prosecution as the health care provider. Do not record physician made error. Instead, chart that Dr. Smith was called to clarify order for analgesic. Include the date and time of phone call, with whom you spoke, and the outcome. Chart only for yourself. You are accountable for information that you enter into a patient's record. Never chart for someone else (exception: if caregiver has left unit for day and calls with information that needs to be documented; include date and time of entry and reference specific date and time to which you are referring and name of source of information in entry; include that information was provided via telephone).

Avoid using generalized, empty phrases such as status unchanged or had good day. This type of documentation is subjective and does not reflect patient assessment. Use complete, concise descriptions of care so documentation is objective and factual. Begin each entry with date and time and end with your signature and title. This guideline ensures that correct sequence of events is recorded; signature documents who is accountable for care delivered. Do not wait until end of shift to record important changes that occurred several hours earlier; be sure to sign each entry (e.g., Mary Marcus, RN). For computer documentation keep your password to yourself. This maintains security and confidentiality. Once logged into computer, do not leave computer screen unattended. Log out when you leave the computer. Make sure that computer screen is not accessible for public viewing.

Accurate
The use of exact measurements establishes accuracy. For example, a description such as Intake, 360 mL of water is more accurate than Patient drank an adequate amount of fluid. Charting that an abdominal wound is 5 cm in length without redness, drainage, or edema is more descriptive than large wound healing well. Accurate measurements help you determine if a patient's condition has changed. Documentation of concise data is clear and easy to understand. It is essential to avoid the use of unnecessary words and irrelevant detail. For example, the fact that the patient is watching television is only necessary when this activity is significant to the patient's status and plan of care. To ensure patient safety use abbreviations carefully to avoid misinterpretation. TJC's do not use list of abbreviations (see Chapter 31) is used by all health care providers to promote patient safety. In addition, TJC (2011) requires that health care institutions develop a list of standard abbreviations, symbols, and acronyms to be used by all members of the health care team when documenting or communicating patient care and treatment. To minimize errors spell out abbreviations in their entirety when they become confusing. Correct spelling demonstrates a level of competency and attention to detail. Many terms can easily be misinterpreted (e.g., dysphagia or dysphasia and dram or gram). Some spelling errors result in serious treatment errors (e.g., the names of certain medications

such as Lamictal and Lamisil or morphine and Numorphan are similar). Transcribe such terms carefully to ensure that the patient receives the correct medication. All entries in medical records must be dated, and there must be a method to identify the authors of all entries (TJC, 2011). Each entry in a patient's record ends with the caregiver's full name or initials and status such as Jane Woods, RN. When initials are used, the full name and status of the individual are found in the medical record to allow others to readily identify the individual. As a nursing student, enter your full name and nursing student (NS) abbreviation, such as David Jones, NS. The abbreviation for nursing student varies between NS for nursing student or SN for student nurse. Include your educational institution when required by agency policy.

Complete
The information within a recorded entry or a report must be complete, containing appropriate and essential information. Criteria for thorough communication exist for certain health problems or nursing activities (Table 26-2). Your written entries in a patient's medical record describe the nursing care you administer and the patient's response. An example of a thorough nurse's note follows: 1915 Verbalizes sharp, throbbing pain localized along lateral side of right ankle, beginning approximately 15 minutes ago after twisting his foot on the stairs. Rates pain as 8 on a scale of 0-10. Pain increased with movement, slightly relieved with elevation. Pedal pulses equal bilaterally. Right ankle circumference 1 cm larger than left. Bilateral lower extremities warm, pale pink, skin intact, responds to tactile stimulation and capillary refill less than 3 seconds. Ice applied to right ankle. Percocet 2 tabs (PO) given for pain. States pain somewhat relieved with ice, rates pain as 6 on a scale of 0-10. Dr. M. Smith notified. Lee Turno, RN 1945 Rates pain as a 3 on a scale of 0-10. States, The pain medication really helped. Lee Turno, RN You frequently use flow sheets or graphic records when documenting routine activities such as daily hygiene care, vital signs, and pain assessments. Describe these data in greater detail when they are relevant such as when a change in functional ability or status occurs. For example, if your patient's blood pressure, pulse, and respirations are elevated above expected values following a walk down the hall, document additional description about the patient's status and response to the walk in the appropriate place in the medical record (e.g., nurse's notes).

Current
Timely entries are essential in a patient's ongoing care. Delays in documentation lead to unsafe patient care. To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient's bedside to facilitate immediate documentation of information as it is collected from a patient. Document the following activities or findings at the time of occurrence:

Vital signs Pain assessment Administration of medications and treatments Preparation for diagnostic tests or surgery, including preoperative checklist

TABLE 26-2 Examples of Criteria for Reporting and Recording

TOPIC CRITERIA TO REPORT OR RECORD Assessment Subjective data Patient's description of episode in quotation marks (e.g., I feel like an elephant is sitting on my chest, and I can't catch my breath.) Describe in patient's own words the onset, location, description of condition (severity, duration, frequency, precipitating, aggravating and relieving factors) (e.g., The pain in my left knee started last week after I knelt on the ground. Every time I bend my knee I have a shooting pain on the inside of the knee.) Patient behavior (e.g., anxiety, confusion, hostility) Onset, behaviors exhibited, precipitating factors, patient's verbal behavior (e.g., pacing in room, avoiding eye contact with nurse, and repeatedly stating, I have to go home now.) Objective data (e.g., rash, tenderness, breath sounds) Onset, location, description of condition (see previous criteria) (e.g., 1100: 2cm raised pale red area noted on back of left hand) Nursing Interventions and Evaluation Treatments (e.g., enema, bath, dressing change) Time administered, equipment used (if appropriate), patient's response (objective and subjective changes) compared to previous treatment (e.g., denied incisional pain during abdominal dressing change, ambulated 300 feet in hallway without assistance) Medication administration

Immediately after administration document: time medication given, preliminary assessment (e.g., pain level, vital signs), patient response or effect of medication; for example: 1500: Reports a throbbing headache all over my head. Rates pain at 6 (scale 0-10). Tylenol 650 mg given PO. 1530: Patient reports pain level 2 (scale 0-10) and states the throbbing has stopped. Patient teaching Information presented, method of instruction (e.g., discussion, demonstration, videotape, booklet), and patient response, including questions and evidence of understanding such as return demonstration or change in behavior Discharge planning Measurable patient goals or expected outcomes, progress toward goals, need for referrals Change in patient's status and who was notified (e.g., physician, manager, patient's family) Admission, transfer, discharge, or death of a patient Treatment for sudden change in patient's status Patient's response to treatment or intervention

Most health care agencies use military time, a 24-hour system that avoids misinterpretation of AM and PM times (Fig. 26-1). Instead of two 12-hour cycles in standard time, the military clock is one 24-hour time cycle. The military clock ends with midnight at 2400 and begins at 1 minute after midnight as 0001. For example, 10:22 AM is 1022 military time; 1:00 PM is 1300 military time.

Organized
Communicate information in a logical order. It is also more effective when notes are concise, clear, and to the point. To document notes about complex situations in an organized fashion think about the situation and make a list of what you need to include before beginning to enter data in the medical record. Applying critical thinking skills and the nursing process gives logic and order to nursing documentation. For example, an organized entry describes the patient's pain, your assessment and interventions, and the patient's response. Use the nursing process to give logic and organization to your documentation.

Methods of Documentation

There are several documentation systems for recording patient data. Regardless whether documentation is entered electronically or on paper, each health care agency selects a documentation system that reflects its philosophy of nursing. The same system is used throughout a specific agency and may be used throughout a health care system as well.

Paper and Electronic Health Records

Traditionally health care professionals documented on paper medical records. Paper records are episode oriented, with a separate record for each patient visit to a health care agency (Hebda et al., 2009). Key information such as patient allergies, current medications, and complications from treatment may be lost from one episode of care (e.g., hospitalization or clinic visit) to the next, jeopardizing a patient's safety. To enhance communication among health care providers and thus patient safety, the American Recovery and Reinvestment Act of 2009 set a goal that all medical records will be kept electronically as of 2014. Many professional organizations and accrediting body initiatives also support initiation of the electronic health record (EHR). The EHR is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting (HIMSS, 2003). Although the electronic medical record (EMR) contains patient data gathered in a health care setting at a specific time and place and is a part of the EHR, the two terms are frequently used interchangeably (Garets and Davis, 2005; Hebda et al., 2009). The EHR provides access to a patient's health record information at the time and place that clinicians need it. A unique feature of an EHR is its ability to integrate all pertinent patient information into one record, regardless of the number of times a patient enters a health care system. An EHR also includes results of diagnostic studies that may include images and sound and decision support software programs. Because an unlimited number of patient records potentially can be stored within an EHR system, health care providers can access clinical data to identify quality issues, link interventions with positive outcomes, and make evidence-based decisions. The EHR improves continuity of health care from one episode of illness to another. A clinician accesses relevant and timely information about a patient and focuses on the priority problems of care to make timely, well-informed clinical decisions. An EHR is a powerful tool because of the decision support resources it contains. For example, in a hospital setting an EHR gathers data and performs checks to support regulatory and accreditation requirements. An EHR includes tools to guide and critique medication administration (see Chapter 31) and basic decision support tools such as physician order sets and interdisciplinary treatment plans. The ultimate development of an EHR for all patients will affect the entire health care community. Currently the American Medical Association, American Nurses Association, the HIMSS, and the American Medical Informatics Association are just some of the organizations gathering information from health care professionals to support the adoption of EHR standards (Hebda et al., 2009). All disciplines and health care organizations will

benefit from the implementation of an EHR. The key advantages of an EHR for nursing include providing a means to compare ongoing clinical data about a patient with original baseline information and maintaining an ongoing record of a patient's health education. In addition, the EHR offers easier access to quality data for research and automates evidencebased guidelines.

Narrative Documentation
Narrative documentation is the traditional method for recording nursing care. It is simply the use of a story-like format to document information specific to patient conditions and nursing care. However, narrative charting has many disadvantages, including the tendency to be repetitious and time consuming and to require the reader to sort through much information to locate desired data (Box 26-1).

Problem-Oriented Medical Record

The problem-oriented medical record (POMR) is a method of documentation that emphasizes patients problems. Data are organized by problem or diagnosis. Ideally each member of the health care team contributes to a single list of identified patient problems. This approach coordinates a common plan of care. The POMR has

FIG. 26-1 Comparison of 24 hours of military time with the hourly positions for civilian time on the clock face.

the following major sections: database, problem list, care plan, and progress notes.

Box 26-1 Examples of Progress Notes Written in Different Formats Narrative Note
Stated I'm dreading surgery. Last time I had a lot of pain when I got out of bed. Discussed alternatives for pain control and importance of postoperative activity. Encouraged to ask for pain medication before pain becomes severe. Stated, I feel better prepared now. Verbalized positive effect of activity on healing and circulation.

SOAP (SubjectiveObjectiveAssessmentPlan)
SI'm worried about what it will be like after surgery. OAsking frequent questions about surgery. Has had no previous experience with surgery. Wife present and supportive.

ADeficient knowledge regarding surgery related to inexperience. Patient also expressing anxiety. PExplain routine preoperative preparation. Demonstrate and explain rationale for turning, coughing, and deep breathing (TCDB) exercises. Provide explanation and teaching booklet on postoperative nursing care.

PIE (ProblemInterventionEvaluation)
PDeficient knowledge regarding surgery related to inexperience. IExplained normal preoperative preparations for surgery. Demonstrated TCDB exercises. Provided booklet on postoperative nursing care. EDemonstrated TCDB exercises correctly. Needs review of postoperative nursing care.

Focus Charting (DataActionResponse)

DStated, I'm worried about what it will be like after surgery. Asking frequent questions about surgery. Has had no previous experience with surgery. Wife present and is supportive. AExplained normal preoperative preparations for surgery. Demonstrated TCDB exercises. Provided booklet on postoperative nursing care. RDemonstrates TCDB exercises correctly. Needs review of postoperative nursing care. States, I feel better knowing a little bit of what to expect.

Database
The database section contains all available assessment information pertaining to a patient (e.g., history and physical examination, the nurse's admission history and ongoing assessment, the dietitian's assessment, laboratory reports, and radiological test results). It is the foundation for identifying patient problems and planning care. As new data become available, you revise the database. It accompanies patients through successive hospitalizations or clinic visits.

Problem List
After analyzing data, health care team members identify problems and make a single problem list. The problem list includes the patient's physiological, psychological, social, cultural, spiritual, developmental, and environmental needs. Team members list the problems in chronological order and file the list in the front of the patient's record to serve as an organizing guide for his or her care. Add new problems as you identify them. When a problem is resolved, record the date and highlight it or draw a line through the problem and its number.

Care Plan
Disciplines involved in the patient's care develop a care plan or plan of care for each problem (see Chapter 18). Nurses document the plan of care in a variety of formats. Generally these plans of care include nursing diagnoses, expected outcomes, and interventions.

Progress Notes
Health care team members monitor and record the progress of a patient's problems. Progress notes come in various formats or structured notes. One method is SOAP charting (see Box 26-1). The acronym SOAP stands for: SSubjective data (verbalizations of the patient) OObjective data (that which is measured and observed) AAssessment (diagnosis based on the data) PPlan (what the caregiver plans to do). An I and E are sometimes added (i.e., SOAPIE) in some institutions. The I stands for intervention, and the E represents evaluation. The logic for SOAPIE notes is similar to that of the nursing process. You collect data about a patient's problems, draw conclusions, and develop a plan of care. The nurse numbers each SOAP note and titles it according to the problem on the list. A second progress note method is the PIE format. It is similar to SOAP charting in its problem-oriented nature. However, PIE charting differs from the SOAP method in that it has a nursing origin, whereas SOAP originated from medical records. The format simplifies documentation by unifying the care plan and progress notes. PIE differs from SOAP notes because the narrative does not include assessment information. A nurse's daily assessment data appear on flow sheets, preventing duplication of data. The narrative note includes PProblem, IIntervention, and EEvaluation. The PIE notes are numbered or labeled according to the patient's problems. Resolved problems are dropped from daily documentation after the nurse's review. Continuing problems are documented daily. A third narrative format is focus charting. It involves use of DAR notes, which include DData (both subjective and objective), AAction or nursing intervention, and R Response of the patient (i.e., evaluation of effectiveness). A DAR note addresses patient concerns: a sign or symptom, condition, nursing diagnosis, behavior, significant event, or change in a patient's condition (see Box 26-1). Documentation follows the nursing process. Nurses broaden their thinking to include any patient concerns, not just problem areas. Focus charting incorporates all aspects of the nursing process, highlights a patient's concerns, and can be integrated into any clinical setting (Mosby, 2006).

Source Records
In a source record a patient's chart has a separate section for each discipline (e.g., nursing, medicine, social work, or respiratory therapy) to record data. Caregivers can easily locate the proper section of the record in which to make entries. Table 26-3 lists the components of a source record. Details about a specific problem are distributed throughout the record. For example, the nurse describes the character of abdominal pain and the use of relaxation therapy and analgesic medication in the nurses notes. The health care provider describes the progress of the patient's bowel obstruction and the plan for surgery in a separate section of the record. The results of x-ray film examinations that show the location of the bowel obstruction are in the test results section of the record. The method by which source records are organized does not show how information from the disciplines is related or how care is coordinated to meet all of the patient's needs.

Charting by Exception
Charting by exception (CBE) focuses on documenting deviations from established norms. This approach reduces documentation time and highlights trends or changes in a patient's condition (Mosby, 2006). It is a shorthand method for documenting normal findings and routine care based on clearly defined standards of practice and predetermined criteria for nursing assessments and interventions. With standards integrated into documentation forms such as predefined normal assessment findings or predetermined interventions, a nurse then only documents significant findings or exceptions to the predefined norms. The nurse writes a progress note only when the standardized statement on the form is not met. Assessments are standardized on forms so all caregivers evaluate and document findings consistently.

TABLE 26-3
SECTIONS CONTENTS

Organization of Traditional Source Record

Admission sheet Specific demographic data about patient: legal name, identification number, gender, age, birth date, marital status, occupation and employer, health insurance, nearest relative to notify in an emergency, religious preference, name of attending physician, date and time of admission Physician's order sheet Record of physician's or other health care provider's orders for treatment and medications with date, time, and signature Nurse's admission assessment Summary of nursing history and physical examination

Graphic sheet and flow sheet Record of repeated observations and measurements such as vital signs, daily weights, and intake and output Medical history and examination Results of initial examination performed by physician, including findings, family history, confirmed diagnoses, and medical plan of care Nurses notes Narrative record of nursing process: assessment, nursing diagnosis, planning, implementation, and evaluation of care Medication records Accurate documentation of all medications administered to patient: date, time, dose, route, and nurse's signature Progress notes Ongoing record of patient's progress and response to medical therapy and review of disease process; often is interdisciplinary and includes documentation from health-related disciplines (e.g., health care providers, physical therapy, social work) Other health care records Includes results from diagnostic tests (e.g., laboratory and x-ray film results), consent forms, and sometimes documentation from health-related disciplines (e.g., radiology, social work); organization of information varies per policies of health care agency Discharge summary Summary of patient's condition, progress, prognosis, rehabilitation, and teaching needs at time of dismissal from hospital or health care agency

Box 26-2

Example of Variance Documentation

A 56-year-old patient is on a surgical unit 1 day after surgery. He has an elevated temperature, his breath sounds are decreased bilaterally in the bases of both lobes of the lungs, and he is slightly confused. Ordinarily 1 day after surgery the patient should be afebrile with lungs clear. The following is an example of the variance documentation for this patient. Breath sounds diminished bilaterally at the bases. T, 100.4; P, 92; R, 28/min; oxygen sat, 84%. Daughter states he is confused and did not recognize her when she arrived a

few minutes ago. Oxygen started at 2 L per standing orders. Will monitor pulse oximetry and vital signs every 15 minutes. Physician notified of change in status. Daughter at bedside. The assumption with charting by exception is that all standards are met unless otherwise documented. When you see entries in the chart, you know that something out of the ordinary has occurred. Thus, when changes in a patient's condition have developed, it is easy to track them. When patients conditions change, enter thorough and precise descriptions of the effects of these changes on patients and the actions taken.

Case Management Plan and Critical Pathways

The case management model of delivering care (see Chapter 2) incorporates an interdisciplinary approach to documenting patient care. Many organizations summarize the standardized plan of care into critical pathways for a specific disease or condition. Critical pathways are interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established time frame. All health care team members use the same critical pathway to monitor a patient's progress during each shift or, in the case of home care, every visit. Critical pathways eliminate nurses notes, flow sheets, and nursing care plans because the document integrates all relevant information. Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway are called variances. A variance occurs when the activities on the critical pathway are not completed as predicted or the patient does not meet the expected outcomes. An example of a variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter is discontinued a day early). A variance analysis is necessary to review the data for trends and for developing and implementing an action plan to respond to the identified patient problems (Box 26-2). In addition, variances often result from changes in the patient's health or because of other health complications not associated with the primary reason for which the patient requires care. Once you identify a variance, you modify the patient's care to meet the needs associated with the variance. Over time health care teams sometimes revise critical pathways if similar variances reoccur.

Common Record-Keeping Forms

A variety of paper or electronic forms are available for the type of information nurses routinely document. The categories within a form are usually derived from institutional standards of practice or guidelines established by accrediting agencies.

Admission Nursing History Forms

A nurse completes a nursing history form when a patient is admitted to a nursing unit. The form guides the nurse through a complete assessment to identify relevant nursing diagnoses

or problems (see Chapter 16). Data provide baseline data to compare with changes in the patient's condition.

Flow Sheets and Graphic Records

Flow sheets allow you to quickly and easily enter assessment data about a patient, including vital signs and routine repetitive care such as hygiene measures, ambulation, meals, weights, and safety and restraint checks. They provide current patient information that is accessible to all members of the health care team. Because there is a coding system for data entry, flow sheets help team members quickly see patient trends over time and decrease time spent on writing narrative notes. If an occurrence on a flow sheet is unusual or changes significantly, enter a focus note. For example, if a patient's blood pressure becomes dangerously high, first complete a focus assessment. You record your assessment and the action taken in the progress notes. Critical and acute care units commonly use flow sheets for all types of physiological data.

Patient Care Summary or Kardex

Many hospitals now have computerized systems that provide information in the form of a patient care summary that is often printed for each patient during each shift. The summary automatically updates as nurses make decisions and data (e.g., orders) are entered into the computer. In some settings a Kardex, a portable flip-over file or notebook, is kept at the nurses station. Most Kardex forms have an activity and treatment section and a nursing care plan section that organize information for quick reference. An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day. The patient care summary or Kardex includes the following information: Basic demographic data (e.g., age, religion) Health care provider's name Primary medical diagnosis Medical and surgical history

Current orders from health care provider (e.g., dressing changes, ambulation, glucose monitoring) Nursing care plan Nursing orders (e.g., education sessions, symptom relief measures, counseling) Scheduled tests and procedures Safety precautions used in the patient's care Factors related to activities of daily living

Nearest relative/guardian or person to contact in an emergency Emergency code status (e.g., indication of do not resuscitate order) Allergies

Standardized Care Plans

Some institutions use standardized care plans to make documentation more efficient. The plans, based on the institution's standards of nursing practice, are preprinted, established guidelines used to care for patients who have similar health problems. After completing a nursing assessment, the nurse identifies the standard care plans that are appropriate for the patient and places the plans in his or her medical record. The nurse modifies the plans to individualize the therapies. Most standardized care plans also allow a nurse to add specific goals or desired outcomes of care and the dates by which these outcomes should be achieved. Standardized care plans are useful when conducting quality improvement audits. They also improve continuity of care among professional nurses. When they are used in a health care facility, the nurse remains responsible for providing individualized care to each patient. Standardized care plans cannot replace a nurse's professional judgment and decision making. Update care plans on a regular basis to ensure that they are current and appropriate.

Discharge Summary Forms

To save costs and ensure appropriate reimbursement, it is important to prepare patients for an effective, timely discharge from a health care institution. A patient's discharge also needs to result in desirable outcomes. Interdisciplinary discharge planning ensures that a patient leaves the hospital in a timely manner with the necessary resources (Box 26-3). Ideally discharge planning begins at admission. By identifying discharge needs early, nursing and other health care professionals can begin planning for home care, support services, and any equipment needs at home. Nurses revise a plan of care as a patient's condition changes. Involve the patient and family in the discharge planning process so they have the necessary information and resources to return home. Discharge documentation includes medications, diet, community resources, follow-up care, and who to contact in case of an emergency or for questions.

Acuity Records
Although acuity records are not part of a patient's medical record, they are useful for determining the hours of care and staff required for a given group of patients. A patient's acuity level, usually determined by a computer program, is based on the type and number of nursing interventions (e.g., intravenous [IV] therapy, wound care, or ambulation assistance) required over a 24-hour period. The acuity level rates patients compared with

one another. For example, an acuity system rates bathing patients from 1 (totally dependent) to 5 (independent). A patient returning from surgery requiring frequent monitoring and extensive care has an acuity level of 1 compared with another patient awaiting discharge after a successful recovery from surgery who has an acuity level of 5. Accurate acuity ratings justify overtime and the number and qualifications of staff needed to safely care for patients. The patient-to-staff ratios established for a unit depend on a composite gathering of 24-hour acuity data for each patient receiving care.

Box 26-3

Discharge Summary Information

Use clear, concise descriptions in the patient's own language. Provide step-by-step description of how to perform a procedure (e.g., home medication administration). Reinforce explanation with printed instructions. Identify precautions to follow when performing self-care or administering medications. Review signs and symptoms of complications that should be reported to the health care provider. List names and phone numbers of health care providers and community resources that the patient can contact. Identify any unresolved problem, including plans for follow-up and continuous treatment. List actual time of discharge, mode of transportation, and who accompanied the patient.

Home Care Documentation

When providing home care, nurses use astute assessment skills to develop a plan of care and gather the needed information about changes in a patient's health care status. This information frequently comes from patient family members. Documentation in the home care system is different from other areas of nursing. Medicare has specific guidelines to establish eligibility for home care reimbursement. Information used for reimbursement comes from a patient's medical record. In addition, home care documentation systems provide the entire health care team with the information needed to enhance teamwork. Documentation is both the quality control and the justification for reimbursement from Medicare, Medicaid, or private insurance companies. Nurses must document all their services for payment (e.g., direct skilled care, patient instructions, skilled observation, and evaluation visits) (TJC, 2011). Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third-party payers. Some parts of the record remain in the home with the patient; other information is needed in an office setting. Thus duplication of documentation is often necessary. Agency policies indicate which forms nurses need to leave at their office versus which forms must be taken into the home. Computerized patient records are evolving to address these different needs. With the use of laptop computers, it is becoming possible for the records to be available in

multiple locations, which allows greater access to information about a patient's interdisciplinary needs.

Long-Term Health Care Documentation

Increasing numbers of older adults and people with disabilities in the United States require care in long-term health care facilities. Nursing personnel often face documentation challenges much different from those in the acute care setting. The Centers for Medicare and Medicaid Services (CMS) establishes guidelines related to accidents and supervision of residents of long-term care facilities. The guidelines require careful documentation for appropriate reimbursement in long-term care agencies (Senft, 2008). You assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set (RAI/MDS). This documentation provides standardized protocols for assessment and care planning and a minimum data set to promote quality improvement within and across facilities (Dellefield, 2007). When residents records are reviewed for reimbursement, there is an expectation that these protocols such as skin assessments, wound care, and assisted ambulation are met. Documentation supports an interdisciplinary approach to the assessment and planning process for patients. Communication among nurses, social workers, recreational therapists, and dietitians is essential in the regulated documentation process. The fiscal support for longterm care residents hinges on the justification of nursing care as demonstrated in sound documentation of the services rendered (Dellefield, 2007).

TABLE 26-4 Reports

DO'S DON'TS

Comparison of Do's and Don'ts of Hand-Off

Provide only essential background information about patient (i.e., name, gender, medical diagnosis, and history). Don't review all routine care procedures or tasks (e.g., bathing, scheduled changes). Identify patient's nursing diagnoses or health care problems and their related causes. Don't review all biographical information already available in written form. Describe objective measurements or observations about patient's condition and response to health problem; emphasize recent changes. Don't use critical comments about patient's behavior such as Mrs. Wills is so demanding.

Share significant information about family members as it relates to patient's problems. Don't make assumptions about relationships among family members. Continuously review ongoing discharge plan (e.g., need for resources, patient's level of preparation to go home). Don't engage in idle gossip. Relay significant changes to staff in the way therapies are to be given (e.g., different position for pain relief, new medication). Don't describe basic steps of a procedure. Describe instructions given in teaching plan and patient's response. Don't explain detailed content unless staff members ask for clarification. Evaluate results of nursing or medical care measures (e.g., effect of back rub or analgesic administration). Don't simply describe results as good or poor. Be specific. Be clear about priorities to which oncoming staff must attend. Don't force oncoming staff to guess what to do first.

Reporting
Nurses communicate information about patients to help team members make appropriate decisions about patient care. It is important that any form of verbal report be timely, accurate, and relevant. Reports commonly used by nurses include hand-off, telephone, and incident reports.

Hand-Off Report
Hand-off reports happen any time one health care provider transfers care of a patient to another health care provider. The purpose of hand-off reports is to provide better continuity and individualized care for patients. For example, if you find that a patient breathes better in a certain position, you relay that information to the next nurse caring for the patient (Table 26-4). Examples of hand-off reports include change-of-shift reports and transfer reports. Standardizing communication during hand-off reports helps ensure patient safety. Hand-off communications include up-to-date information about a patient's condition, required care, treatments, medications, services, and any recent or anticipated changes. Information

during patient hand-off can be given face-to-face, in writing, or verbally such as over the telephone or via audiorecording. Regardless of the way hand-off reports are given, it is essential for staff to have an opportunity for last-minute updates, to clarify information, or to receive information on care events or changes in a patient's condition. Properly performed, a hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care (Schroeder, 2006).

Box 26-4 Guidelines for Telephone and Verbal Orders

Clearly determine the patient's name, room number, and diagnosis. Repeat any prescribed orders back to the physician or health care provider. Use clarification questions to avoid misunderstandings.

Write TO (telephone order) or VO (verbal order), including date and time, name of patient, the complete order; sign the name of the physician or health care provider and nurse. Follow agency policies; some institutions require telephone (and verbal) orders to be reviewed and signed by two nurses. The health care provider must co-sign the order within the time frame required by the institution (usually 24 hours). An effective hand-off report is quick and efficient. A good report provides a baseline for comparisons and indicates the kind of care anticipated for the next nurse who will be caring for the patient. An organized and concise approach helps you set goals and anticipate patient needs and lessens the chance of overlooking important information. A sample format follows: background information (name, age, and medical diagnosis); primary health problem; unusual occurrences; discharge planning issues; identification of significant changes in measurable terms (e.g., pain scale); observations; findings; time when new, STAT, or prn medications were given; care required such as medications that need to be started, when to assess the effectiveness of STAT/prn medications, or when a dressing needs to be changed next; progress with teaching; interventions; and family involvement. It is especially important to report any recent changes or priority situations concerning a patient's condition. Report elements do not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about a patient or family, which could possibly lead to legal charges if overheard by the patient or family (Benson et al., 2007). This type of language contributes to prejudicial opinions about a patient.

Telephone Reports and Orders Telephone Reports

A registered nurse makes a telephone report when significant events or changes in a patient's condition have occurred. A telephone report needs to include clear, accurate, and concise information. About 60% of the worst type of medical errors, called sentinel events, relate to communication problems that often arise during telephone reports (Hemmila, 2006). Thus some institutions use SBAR, an acronym that stands for Situation-Background-Assessment-Recommendation. SBAR standardizes telephone communication of significant events or changes in a patient's condition and is a communication strategy designed to improve patient safety. For example, when describing the situation, you include both the admitting and secondary diagnoses and the problem your patient is having as the current issue. Background information includes pertinent medical history, previous laboratory tests and treatments, psychosocial issues, allergies, and current code status. For assessment data include significant findings in your head-to-toe physical assessment, recent vital signs, current treatment measures, restrictions, recent laboratory results and diagnostics, and pain status. Then provide your recommendation, in which you suggest a plan of care and what needs to be addressed (Hemmila, 2006). Document every phone call you make to a health care provider. Documentation includes when the call was made, who made it (if you did not make the call), who was called, to whom information was given, what information was given, what information was received, and verification of the information with the provider. Health care institutions have a process for a verification read back when receiving information or critical test results. An example follows: Laboratory technician J. Ignacio reported a potassium level of 5.9. Dr. Wade notified at 2030. Information transcribed and read back for verification. Ordered change in IV fluids. D5NS 1000 mL to run at 125 mL per hour. D. Markle, RN, read back.

Telephone and Verbal Orders

A telephone order (TO) occurs when a health care provider gives an order over the phone to a registered nurse. A verbal order (VO) involves the health care provider giving orders to a nurse while they are standing near each other. TOs and VOs usually occur at night or during emergencies and frequently cause medical errors (Bombard, 2008). The nurse receiving a TO or VO writes down the complete order or enters it into the computer as it is being given. Then he or she reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct (Bombard, 2008). An example follows: 10/16/2011: 0815, Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Knight/J. Woods, RN, read back. The health care provider later verifies the TO or VO legally by signing it within a set time (e.g., 24 hours) as set by hospital policy. TOs and VOs are used only when absolutely necessary and not for the sake of convenience. In some situations it is prudent to have a second person listen to TOs. Check agency policy. Box 26-4 provides guidelines that promote accuracy when receiving TOs.

Incident or Occurrence Reports

An incident or occurrence is any event that is not consistent with the routine operation of a health care unit or routine care of a patient. Examples of incidents include patient falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of ordered therapies, and circumstances that lead to injury or a risk for patient injury. Analysis of incident reports helps with the identification of trends in systems and unit operations that provide justification for changes in policies and procedures or for in-service seminars. Incident (or occurrence) reports are an important part of the quality improvement program of a unit (see Chapter 5). Always contact the patient's health care provider whenever an incident happens. Note that you do not mention the incident report in the patient's medical record. Instead you document an objective description of what happened, what you observed, and the followup actions taken in the patient's medical record. It is important to evaluate and document the patient's response to the error or incident. Follow agency policy when making an incident report. These reports are an important part of quality improvement. The overall goal is to identify changes needed to prevent future recurrence. File the report with the appropriate risk-management department of the agency. Analysis of incident or occurrence reports helps identify trends in an organization that provide justification for changes in policies and procedures or for in-service programs.

Health Informatics
Health informatics is defined by the American Medical Informatics Association (AMIA) as, The application of computer and information science in all basic and applied biomedical sciences to facilitate the acquisition, processing, interpretation, optimal use, and communication of health-related data. The focus is the patient and the process of care, and the goal is to enhance the quality and efficiency of care provided (Hebda et al., 2009). Nursing competence in health care informatics is becoming a priority as health care facilities adopt EMRs/EHRs and other technologies. A recent survey found that only 28% of primary care physicians in the United States used EMRs in practice (Davis et al., 2009). Another survey of 2952 hospitals in the United States reported that only 1.5% of U.S. hospitals have a comprehensive EHR system in place and 10.9% were using a basic EHR (Jha et al., 2009). Use of EMRs/EHRs is increasing as a result of the creation of the federal Health Information Technology for Economic and Clinical Health Act (HITECH) in 2009. The government will make incentive payments totaling over $27 billion over a 10-year period to health care agencies and provider's offices that adopt EHRs and use data meaningfully from the EHR to promote safe, high-quality patient care resulting in positive patient outcomes (Blumenthal, 2010). In addition, penalties will be assessed to health care facilities that do not adopt EHRs or show meaningful use of data generated from EHRs.

Nursing Informatics
All nurses deal with data, information, and knowledge (Hebda et al., 2009). It is important that you know how to record, interpret, and report data and critically think and apply knowledge to use information for patient care. Data include numbers, characters, or facts that you collect according to a perceived need for analysis and possible action. You gain

knowledge from gathering and using information from several sources (Hebda et al., 2009). An example is a nurse's observation of a wound's edges, color of drainage, and measurement of the length of a wound. When a nurse examines data describing the condition of the wound over time, a pattern develops showing that the wound is not healing (information). On the basis of evidence available in the scientific literature, the nurse applies knowledge of wound care principles and intervenes to manage the patient's wound. In health care settings it is a challenge to easily access data and information about patients. This is especially true when information is recorded manually on printed forms. For example, a nurse working in risk management who is interested in investigating patient falls has to review page by page the records of patients who have fallen to identify the common factors contributing to falls. Remember that three important purposes of medical records are communication, education, and research. When a health care organization relies on handwritten patient records, the process of locating, summarizing, and comparing information is slow and difficult. Thus it becomes even more difficult to access information in a timely manner to provide or improve patient care. It also becomes difficult to locate data sources for research purposes. Furthermore, when data about patients are compared manually, it is more difficult to see the trends that help educate staff about patient care. The most efficient way to use data and information to improve quality of care, complete research, and provide education is through information technology (Institute of Medicine, 2001). Information technology (IT) refers to the management and processing of information, generally with the assistance of computers (Hebda et al., 2009). Advances in technology allow health care agencies to move from paper-based medical records to computer-based records. A health care information system (HIS) is a group of systems used within a health care organization to support and enhance health care (Hebda et al., 2009). A HIS consists of two major types of information systems: clinical information systems (CISs) and administrative information systems. Together the two systems operate to make the entry and communication of data and information more efficient. You will find that any single health care agency uses one or several CISs and administrative information systems. For example, a small community hospital uses a nursing information system (NIS); an order entry system; and laboratory, radiology, and pharmacy systems to coordinate their core patient care services. A nurse working in such a hospital documents nursing care on a computer, locates and reviews laboratory test results, orders sterile supplies, and enters health care provider orders for x-ray films and patients medications. Many hospitals now use NISs to support the documentation of nursing process activities and offer resources for managing nursing care delivery. A reliable NIS is the product of nursing informatics. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice (American Nurses Association, 2008). It facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision making in all roles and settings. The application of nursing informatics results in an efficient and effective NIS. An expertly designed CIS based on nursing informatics integrates and supports clinical judgments with up-to-date evidencebased practice. An effective NIS meets two goals. First, it supports the way that nurses

function and work by providing them the flexibility to use the system to view data and collect information, provide patient care, and document a patient's condition and care provided. Second, it supports and enhances nursing practice through improved access to information and clinical decision-making tools (Hebda et al., 2009). In the fast-paced world of nursing, nursing informatics plays an important role in helping nurses make decisions more rapidly and accurately. It has revolutionized how health care providers locate or mine patient data to look for trends and patterns between patient outcomes and care provided by nurses. New technologies also allow nurses to study the effect of systems on error reduction and patient safety. Through the application of nursing informatics, practical applications of technology enhance bedside care and education. Numerous groups, including the ANA (2008), recommend that all nurses acquire a minimal level of awareness and competence in informatics and use of IT. Competence in informatics is not the same as computer competency. To become competent in informatics you need to be able to use evolving methods of discovering, retrieving, and using information in practice (Hebda et al., 2009). This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. For example, you need to know how to acquire, critique, and apply scientific evidence from literature databases (see Chapter 5). As a nurse you also need to know how to use clinical databases within your institution and apply the information so you can deliver high-quality, appropriate patient care.

Nursing Information Systems

A good information system that incorporates principles of nursing informatics supports the work you do. As a nurse you need to access a computer program easily, review the patient's medical history and health care provider orders, and then go to the patient's bedside to conduct a comprehensive assessment. Once you have completed the assessment, you enter data into the computer terminal at the patient's bedside and develop a plan of care from the information gathered. This allows you to quickly share the plan of care with the patient. Periodically you return to the computer to check on laboratory test results and document the therapies you administer. The computer screens and optional pop-up windows make it easy to locate information, enter and compare data, and make changes. NISs have two designs. The nursing process design is the most traditional. It organizes documentation within well-established formats such as admission and postoperative assessment problem lists, care plans, discharge planning instructions, and intervention lists or notes. More advanced systems incorporate standardized nursing languages such as the North American Nursing Diagnosis Association (NANDA) International nursing diagnoses, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) into the software. For example, the documentation of nursing admission assessment findings relies on a menu-driven approach. A menu lists related commands that you select from the computer screen to complete the patient assessment. The commands direct you through various assessment categories such as a patient's medication history, nutritional status, psychosocial history, and review of systems. After

you enter assessment data into a computer, a program offers menu lists for the selection of nursing diagnoses and interventions, allowing you to individualize a patient's care plan. Another example is a program for discharge instructions. After you enter the necessary information for a patient's discharge instructions, follow-up appointments, and medication information, the system generates printed copies of the instructions for you to review and give to patients on discharge. You place a copy in the patient's record. This information is also available for home care staff and the patient's health care provider. The nursing process design includes formats for the following: Generation of a nursing work list that indicates routine scheduled activities related to the care of each patient Documentation of routine aspects of patient care such as hygiene, positioning, fluid intake and output, wound care measures, and blood glucose measurements Progress note entries using narrative notes, charting by exception, and flow-sheet charting Documentation of medication administration (see Chapter 31)

The second design model for a NIS is the protocol or critical pathway design (Hebda et al., 2009). This design offers an interdisciplinary format to manage information. All health care providers use a protocol system to document the care they provide. Evidencebased clinical protocols or critical pathways provide the formatting or design for the type of information that clinicians enter into the system. The information system allows a user to select one or more appropriate protocols for a patient. An advanced system merges multiple protocols, using a master protocol or path to direct patient care activities. Standard health care provider order sets are included in the protocols and automatically processed. The system integrates appropriate information into the medication delivery process to enhance patient safety. In addition, the system identifies variances of the anticipated outcomes on the protocols as they are charted.

FIG. 26-2 Model of a nursing clinical decision support system (NCDSS).

(Courtesy Frank Lyerla.) This provides all caregivers the ability to analyze variances and offer an accurate clinical picture of a patient's progress. Clinical decision support systems (CDSSs) are computerized programs used within the health care setting to support decision making (Lyerla, 2008). When used to support nursing decisions it is called a nursing CDSS (Fig. 26-2). A CDSS is based on rules and if-then statements, linking information and/or producing alerts, warnings, or other information to the user. The information within a CDSS is current, is evidence based, and has the ability to be updated. Information provided by a CDSS is given to the right person at the right time. For example, an effective CDSS notifies health care providers of patient allergies before ordering a medication. This enhances patient safety during the medication ordering process. CDSSs also improve nursing care. When patient assessment

data are combined with patient care guidelines, nurses are better able to implement evidence-based nursing care, resulting in improved patient outcomes (Box 26-5).

Advantages of a Nursing Information System

Anecdotal reports and descriptive studies suggest that NISs offer important advantages to nurses in practice. Hebda et al. (2009) outline some specific advantages: Increased time to spend with patients Better access to information Enhanced quality of documentation Reduced errors of omission Reduced hospital costs Increased nurse job satisfaction Compliance with requirements of accrediting agencies (e.g., TJC) Development of a common clinical database

The transition to computerized documentation presents both opportunities and challenges to nurses and nurse managers. A barrier to the successful implementation of a CIS is the reluctance of some nurses and other clinical staff to accept technological advances. Often clinicians fail to understand how technology can improve the way they deliver care and enhance clinical decision processes. The successful implementation of a NIS requires preparation, involvement, and commitment of the entire nursing staff. The process is complex and includes more than just implementing a new technology. It is important to address educating staff, changing attitudes and cultures, and standardizing documentation and health care practices (Oroviogoicoechea et al., 2007). Successful integration requires nurses to understand the potential of informatics and IT. Although promoters of NISs suggest that adoption of computerized charting provides time saving for nursing workload, currently there is inconsistent evidence of time saved with use of electronic patient records (Choi et al., 2006).

Box 26-5 Effect of Clinical Decision Support Systems (CDSS) on patient outcomes
PICO Question: Do nurses who work at health care agencies that use CDSS provide safer and more effective patient care when compared with nurses who work at agencies that do not use CDSS?

Evidence Summary
Nurses who provide evidence-based care at the bedside provide safe and effective care. However, one barrier to evidence-based nursing care is getting information to

nurses at the bedside when they need it. Several studies investigated the effect of CDSS on patient outcomes. For example, Lyerla et al. (2010) found that nurses are more likely to follow evidence-based guidelines when caring for patients who are on ventilators when the CDSS combined interventions for ventilator-associated pneumonia with nursing assessment data. The use of CDSS is also linked with adherence to implementation of evidence-based sepsis care in intensive care units (Giuliano, Lecardo, and Staul, 2011) and completion of screening for osteoporosis in primary care settings (DeJesus et al., 2011). These studies show that CDSS that provide automatic decision support at the time and place nurses need it enhances the quality and safety of patient care. CDSS also help nurses initiate evidence-based care faster and with more accuracy, improving patient outcomes.

Application to Nursing Practice

CDSS enhance the implementation of evidence-based practice into nursing care because they remind nurses which interventions need to be implemented for specific patients at the time the care is needed. Nurses need to be involved in the design and selection of CDSS to ensure that clinical decision support is provided effectively and efficiently. Nurses need to evaluate patient outcomes when CDSS are used. They also need to be involved in developing solutions to improve the effectiveness of CDSS when opportunities for improvement are identified.

Privacy, Confidentiality, and Security Mechanisms

Computerized documentation has legal risks. It is possible for anyone to access a computer station within a health care agency and gain information about almost any patient. Therefore protection of information and computer systems is a top priority. Confidentiality of access to computerized records is a major issue, particularly with the implementation of HIPAA. HIPAA was the first federal legislation to protect automated patient records and uniform personal health information (PHI) nationwide (Hebda et al., 2009). PHI includes individually identifiable health information such as demographic data; facts that relate to an individual's past, present, or future physical or mental health condition; provision of care; and payment for the provision of care that identifies the individual (Hebda et al., 2009). Most security mechanisms for information systems use a combination of logical and physical restrictions to protect information and computer systems. They include measures such as firewalls and the installation of antivirus and spyware-detection software. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information. For example, an automatic signoff is a safety mechanism that logs a user off the computer system after a specified period of inactivity (Hebda et al., 2009). An automatic sign-off is used in most patient care areas and other departments that handle sensitive data.

Physical security measures include placing computers or file servers in restricted areas or using privacy filters for computer screens visible to visitors or others without access. This form of security has limited benefit, especially if an organization uses mobile wireless devices such as notebooks, tablet personal computers (PCs), and personal digital assistants (PDAs). These devices are easily misplaced or lost, falling into the wrong hands. Some organizations use motion detectors or alarms with these devices to help prevent theft. Access or log-in codes along with passwords are frequently used for authenticating access to electronic records. A password is a collection of alphanumeric characters that a user types into a computer before accessing a program. A user usually needs to enter a password after the entry and acceptance of an access code or user name. A password does not appear on the computer screen when it is typed, nor should it be known to anyone but the user and information system administrators (Hebda et al., 2009). Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. A good system requires frequent and random changes in personal passwords to prevent unauthorized persons from tampering with records. In addition, most staff have access only to patients in their work area. Some staff (e.g., administrators or risk managers) have authority to access all patient records. To protect patient privacy, health care agencies track who accesses patient records and when they access them. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information.

Handling and Disposal of Information

It is extremely important to keep medical records confidential. However, it is equally important to safeguard the information that is printed from the record or extracted for report purposes. For example, you print a copy of a nursing activities work list to use as a day planner while administering care to patients. You refer to information on the list and write notes to enter later into the computer. Information on the list is PHI, must be kept confidential, and cannot be left out for view by unauthorized persons. You destroy (e.g., shred) anything that is printed when the information is no longer needed. Printing and faxing information from a patient's record is a primary source for the unauthorized release of information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient's name or address) must be destroyed. Most agencies have shredders or locked receptacles for shredding and later incineration. Nurses also work in settings where they are responsible for erasing computer files from the hard drive that contain calendars, surgery or diagnostic procedure schedules, or other daily records that contain PHI (Hebda et al., 2009). Know and follow the disposal policies for records in the institution where you work. Institutions need to have sound policies for the use of fax machines, specifically which type of information can be sent and to which departments. Information that you send by

fax should not exceed that requested or required for immediate clinical needs. The following are some steps to take to enhance fax security (Hebda et al., 2009): Confirm that fax numbers are correct before sending to be sure that you direct information properly. Use a cover sheet, especially if a fax machine serves a number of different users.

Authenticate at both ends before data transmission to verify that source and destination are correct. Use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. Place fax machines in a secure area. Limit machine access to designated individuals.

Log fax transmissions. This feature is often available electronically on the machine.

Clinical Information Systems

Any clinician, including nurses, physicians, pharmacists, social workers, and therapists, uses programs available on a Clinical Information System (CIS). These programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. A monitoring system includes devices that automatically monitor and record biometric measurements (e.g., vital signs, oxygen saturation, cardiac index, and stroke volume) in critical care and specialty areas. The devices electronically send measurements directly to the nursing documentation system. Order-entry systems allow nurses to order supplies and services from another department. An example is the ability to order sterile supplies from the central supply department. This eliminates written order forms and expedites the delivery of needed supplies to a nursing unit. Computerized provider order entry (CPOE) is a process by which a health care provider directly enters orders for patient care into the hospital information system. In advanced systems CPOE has built-in reminders and alerts that help a health care provider select the most appropriate medication or diagnostic test. The Institute of Medicine has instituted major initiatives to improve the quality of care and reduce medication errors. Many believe that CPOE is one answer. The direct entry of orders eliminates issues related to illegible handwriting and transcription errors. In addition, a CPOE system potentially speeds the implementation of ordered diagnostic tests and treatments, which improves staff productivity and saves money (Hebda et al., 2009) because the unit secretary no longer transcribes a written order onto a nursing order form. Orders made through CPOE are integrated within the record and sent to the appropriate departments (e.g., pharmacy or radiology).

Key Points
The medical record is a legal document and requires information describing the care that is delivered to a patient. The computerized health record (or electronic health record) is a digital version of a patient's medical record. All information pertaining to a patient's health care management that is gathered by examination, observation, conversation, or treatment is confidential. Access to patient records is limited to individuals involved in the care of the patient. Interdisciplinary communication is essential within the health care team. Accurate record keeping requires an objective interpretation of data with precise measurements, correct spelling, and proper use of abbreviations. A nurse's signature on an entry in a record designates accountability for the contents of that entry. Any change in a patient's condition warrants immediate documentation about the event and the action that was taken to keep a record accurate. The medical record is a financial record that serves as the basis for reimbursement. Problem-oriented medical records are organized by the patient's health care problems. The intent of SOAP, SOAPIE, PIE, or DAR charting formats is to organize entries in the progress notes according to the nursing process. Medicare guidelines for establishing a patient's home care cost reimbursement is the basis for documentation by home care nurses. Long-term care documentation is interdisciplinary and closely linked with fiscal requirements of outside agencies. Computerized Information Systems (CIS) provide information about patients in an organized and easily accessible fashion. The major purpose of the hand-off report is to maintain continuity of care. Rounds allow nurses to perform needed assessments, evaluate patients progress, and determine the best interventions for a patient's needs. Always verify patient care information communicated by telephone using the read back process.

 A hospital information system consists of two major types of information systems: CIS and administrative information systems. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision making in all roles and settings. Protection of the confidentiality of patients health information and the security of computer systems are top priorities that include log-in processes, audit trails, firewalls, data recovery processes, and policies about handling and disposing of data to protect patient information.

Clinical Application Questions Preparing for Clinical Practice

David Page, an 80-year-old man, is admitted to the hospital with a diagnosis of possible pneumonia. He states that he is not feeling well and has a frequent productive cough, which is worse at night. Vital signs are: blood pressure, 150/90 mm Hg; pulse rate, 92 beats/min; respirations, 22 breaths/min. During your initial assessment he coughs violently for 40 to 45 seconds. His lungs have wheezes and rhonchi in both bases and are otherwise clear. He states, My chest hurts when I cough, and the pain radiates into my arm. 1 2 Which data do you document as objective? Which data are subjective?

3 The nurse documents assessment findings in an electronic documentation system in narrative format. Discuss the problems associated with this style of documentation. Answers to Clinical Application Questions can be found in the Pageburst Integrated Resources box.

Review Questions Are You Ready to Test Your Nursing Knowledge?

1 A manager who is reviewing the nurses notes in a patient's medical record finds the following entry, Patient is difficult to care for, refuses suggestion for improving appetite. Which of the following directions does the manager give to the staff nurse who entered the note? 1 2 Avoid rushing when charting an entry. Use correction fluid to remove the entry.

3 4

Draw a single line through the statement and initial it. Enter only objective and factual information about the patient.

2 A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: 1 Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. 2 Gives a newly ordered medication before entering the order in the patient's medical record. 3 Reads the orders back to the health care provider after receiving them and verifies their accuracy. 4 Asks the preceptor to listen in on the phone conversation.

3 As you enter the patient's room, you notice that he is anxious to say something. He quickly states, I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this. Which of the following is the most appropriate documentation of the patient's emotional status? 1 The patient has a defiant attitude and is demanding his test results.

2 The patient appears to be upset with his nurse because he wants his test results immediately. 3 The patient is demanding and complains frequently about his doctor.

4 The patient stated that he felt frustrated by the lack of information he received regarding his tests. 4 You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care? Which of the following is the best response? 1 2 HIPAA allows all hospital staff access to your medical record. HIPAA limits the information that is documented in your medical record.

3 HIPAA provides you with greater control over your personal health care information. 4 HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

5 to: 1 2 3 4 6 1 2

A patient asks for a copy of her medical record. The best response by the nurse is State that only her family may read the record. Indicate that she has the right to read her record. Tell her that she is not allowed to read her record. Explain that only health care workers have access to her record. Which of the following charting entries is most accurate? Patient walked up and down hallway with assistance, tolerated well. Patient up, out of bed, walked down hallway and back to room, tolerated well.

3 Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. 4 Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise. 7 Match the correct entry with the appropriate SOAP (SubjectiveObjective AssessmentPlan) category. 1. S a. Repositioned patient on right side. Encouraged patient to use patientcontrolled analgesia (PCA) device. 2. O b. The pain increases every time I try to turn on my left side. 3. A c. Acute pain related to tissue injury from surgical incision. 4. P d. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. 8 On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system?

1 2 3 4

Information technology. Electronic health record. Personal health information. Administrative information system.

9 You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) 1 2 3 4 The patient's name, age, and admitting diagnosis Allergies to food and medications Your evaluation that the patient is needy How much the patient ate for breakfast

5 That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol 10 You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: 1 2 3 4 Documented medication given by another nursing student. Included the date and time of all entries in the chart. Stood with his back against the wall while documenting on the computer. Signed all documentation electronically.

11 A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? 1 2 CPOE reduces transcription errors. CPOE reduces the time necessary for health care providers to write orders.

3 Health care providers can write orders from any computer that has Internet access. 4 CPOE reduces the time nurses use to communicate with health care providers.

12 You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? 1 The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. 2 You need to use words the patients can understand when writing the directions.

3 The form needs to be given to patients in a sealed envelope to protect their health information. 4 The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home. 13 A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? 1 2 3 4 Electronic health record Clinical documentation Clinical decision support system Computerized physician order entry

14 While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: 1 2 3 4 15 1 2 3 The nurses forgot to document on the pulmonary system. The nurses were charting by exception. The computer is not working correctly. The physician does not have authorization to view the nursing assessment. What is an appropriate way for a nurse to dispose of printed patient information? Rip several times and place in a standard trash can Place in the patient's paper-based chart Place in a secure canister marked for shredding

Burn the documents

Answers: 1. 4; 2. 2; 3. 4; 4. 3; 5. 2; 6. 4; 7. 1b, 2d, 3c, 4a; 8. 2; 9. 1, 2, 5; 10. 1; 11. 1; 12. 2; 13. 3; 14. 2; 15. 3.

References
American Nurses Association: Principles for documentation, principles for practice: a resource package for registered nurses. 2005, The Association, Silver Spring, Md. American Nurses Association: Scope and standards of nursing informatics practice. 2008, American Nurses Publishing, Washington, DC. Benson, E, et al.: Improving nursing shift-to-shift report. J Nurs Care Qual. 22(1), 2007, 80. Blumenthal, D: The meaningful use regulation for electronic health records. N Engl J Med. 363(6), 2010, 501. Bombard, C: Lines of communication. Nurs Spectr (Gt Chic Ne Ill NW Indiana Ed). 21(4), 2008, 24. Choi, WH, et al.: Comparison of direct and indirect nursing-care times between physician order entry system and electronic medical records. Stud Health Technol Inform. 122, 2006, 288. Davis, K, et al.: Health information technology and physician perceptions of quality of care and satisfaction. Health Policy. 90, 2009, 239. Dellefield, M: Implementation of the resident assessment instrument/minimum data set in the nursing home as organization: implications for quality improvement in RN clinical assessment. Geriatr Nurs. 28(6), 2007, 377. Garets, D, Davis, M: Electronic medical records vs. electronic health records: yes, there is a difference; White Paper, August 26, HIMSS Analytics LLC www.himssanalytics.com/docs/WP_EMR_EHR.pdf, 2005, Accessed August 24, 2011. Healthcare Information and Management Systems Society (HIMSS): EHR definition, attributes, and essential requirements, version 1.1, September 24 http://www.himss.org/content/files/ehrattributes070703.pdf, 2003, accessed July 28, 2010. Hebda, T, et al.: Handbook of informatics for nurses and health care professionals. ed 4, 2009, Pearson Prentice Hall, Upper Saddle River, NJ. Hemmila, D: Talking the talk: hospitals use SBAR to standardize communication. NurseWeek. 7(17), 2006, 26.

Institute of Medicine: Crossing the quality chasm: a new health system for the twentyfirst century. 2001, National Academies Press, Washington, DC. Lyerla, F: Design and implementation of a nursing clinical decision support system to promote guideline adherence. Computers Inform Nurs. 26(4), 2008, 227. 2006. In Mosby's surefire documentation: how, what, and when nurses need to document. ed 2, 2006, Mosby, St Louis. Oroviogoicoechea, C, et al.: Review: evaluating information systems in nursing. J Clin Nurs. 17(5), 2007, 567. Schroeder, S: Picking up the PACE: a new template for shift report. Nursing. 36(10), 2006, 22. Senft, D: Accidents and supervision: new CMS F-tag guidance. Geriatr Nurs. 29(1), 2008, 12. The Joint Commission (TJC): Comprehensive accreditation manual for hospitals: the official handbook (E-dition), The Joint Commission, 2011.

Research References
DeJesus, RS, et al.: Predictors of osteoporosis screening completion rates in a primary care practice. Popul Health Manage. 14(5), 2011, 243. Giuliano, KK, Lecardo, M, Staul, L: Impact of protocol watch on compliance with the Surviving Sepsis campaign. Am J Crit Care. 20(4), 2011, 313. Jha, A, et al.: Use of electronic health records in US hospitals. N Engl J Med. 360(16), 2009, 1628. Lyerla, F, et al.: A nursing clinical decision support system and potential predictors of head-of-bed position for patients receiving mechanical ventilation. Am J Crit Care. 19(1), 2010, 39.

Pageburst Integrated Resources

As part of your Pageburst Digital Book, you can access the following Integrated Resources:

Answer Keys

Answer Key Clinical Application Questions and Rationales Answer Key - Review Questions and Rationales

Case Studies
Case Study Case Study with Answers

Key Terms
Key Term Flashcards

Additional Resources
QSEN: Building Competency Scenario and Answers (Potter, 2013, p. 348) Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4