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Guideline at a Glance: Information Management
Guideline at a Glance: Information Management The AORN Guideline at a Glance is a key component of the Guideline Essentials, a suite of online implementation tools designed to help the perioperative team translate AORN’s evidence-based guidelines into practice. Each Guideline at a Glance highlights important elements of the full guideline and includes images, implementation steps, and the rationale for why these steps are important to promote safety and optimal outcomes for patients undergoing operative and other invasive procedures. Facilities can provide team access to the entire set of Guideline Essentials through a subscription to the multiuser, online edition (eSubscription) of the AORN Guidelines for Perioperative Practice. Individuals can obtain the same access through a subscription to the AORN Guideline eBook Mobile App. For more information about the complete set of implementation tools included in the Guideline Essentials, visit https://www.aorn.org/guidelines/purchase-guidelines/ guideline-essentials. PATIENT DATA COLLECTION
NURSING WORKFLOW
• Record in the patient’s health care record: - assessment findings (eg, physical, psychosocial, cultural, spiritual) - clinical problems - communication with other health care professionals - communication with and education of the patient - patient care orders, order acknowledgment, implementation, and management - nursing interventions performed, the time performed, the location of care, and the person performing the care - expected and interim patient outcomes - reassessment findings - local, state, and national regulatory requirements - mandatory reporting criteria for quality performance reimbursement - data important to ongoing and transitional care
• Synchronize perioperative nursing documentation with the nursing workflow. • Facilitate data capture using a format designed to support clinical workflow activities and eliminate redundancy in data entry.
• Collect and record patient data concurrently with each assessment, reassessment, or evaluation. The perioperative patient health care record reflects the plan of care and evaluation of progress toward the desired outcome.
272 | AORN Journal
• Evaluate perioperative electronic documentation systems for their ability to accommodate the objectives of the health care facility. Clinical information systems should address: - clinical workflow - patient safety - information needs of the patient care environment - patient population characteristics - clinician and provider usability requirements • If used, charting by exception processes should be formatted and reviewed by the health care organization’s risk management and legal representatives. Effective information systems collect, store, and organize patient information to allow real-time updates, support clinical decision making, and be accessible to health care professionals when needed. http://dx.doi.org/10.1016/S0001-2092(17)30709-3 © AORN, Inc, 2017 www.aornjournal.org
September 2017, Volume 106, No. 3
Guideline at a Glance
• Tailor patient health information to allow for the collection of unique patient care data (eg, communicable diseases, responses to medications, psychosocial considerations) that may affect the planned operative or other invasive procedure. • When using standing orders or preprinted order sets, do not use unacceptable abbreviations, eliminate trailing zeros in medication dosages, use standardized names and terms, and have the surgeon review for accuracy.
STRUCTURED VOCABULARY • Use a structured vocabulary (eg, the Perioperative Nursing Data Set [PNDS]) that is inclusive of the nursing process workflow and represents each phase of the perioperative patient care continuum (ie, preadmission, preoperative, intraoperative, postoperative). • Incorporate nursing process workflow and require unambiguous representation of the patient experience in each phase of perioperative nursing documentation. • Implement a documentation system that includes the PNDS and a standardized perioperative electronic framework. • Incorporate the standardized clinical terminologies identified by the US government to promote interoperability of health care data. A structured vocabulary describes patient care using controlled (ie, standardized) and unambiguous terms that are interpreted with consistent meaning among health care clinicians. PROFESSIONAL AND REGULATORY COMPLIANCE • Enter patient care orders into the clinical documentation system as close as possible to the time the order is communicated or the intervention is initiated. • Document verbal orders when they are communicated and verify them using a readback process that involves the ordering health care practitioner. • Record the names and roles of individuals participating in the patient’s perioperative care, as well as those not directly involved in the scheduled surgical or procedural intervention.
www.aornjournal.org
Patient care information collected and entered into the health care record is a tool for monitoring and evaluating the patient’s health status and response to care, a resource for evaluating compliance with regulatory requirements, and a method for aligning provision of services for reimbursement.
INFORMED CONSENT • Include in your documentation a complete and accurate informed patient consent for each surgical or invasive procedure to be performed. Include: - the name of the health care facility providing the surgery or invasive procedure - the specific name of the intervention to be performed - indications for the proposed intervention - the name of the responsible health care provider performing the intervention - risks and benefits associated with the proposed intervention - discussion of the risks and benefits with the patient or patient’s legal representative - the signature of the patient or the patient’s legal representative - the date and time the patient or the patient’s legal representative signed the informed consent document
AORN Journal | 273
Guideline at a Glance
- the date and time and the signature of the person who witnessed the patient or patient’s legal representative signing the informed consent document - the signature of the responsible health care provider who executed the informed consent discussion with the patient or patient’s legal representative - additional information required by state statutes or administrative rules, which may include other persons present in the procedure room (eg, assistant surgeon, medical residents, RN first assistant) The informed consent process must be documented for procedures and treatments that are identified in the health care facility’s medical staff policies as requiring informed consent. The patient or the patient’s legal representative is entitled to participate in the informed decisionmaking process, including the right to request or refuse treatment. ACCESS • Limit access to patient health information to authorized individuals based on the health care role (eg, surgeon, RN, perfusionist), responsibility, and function (eg, postanesthesia care unit RN assisting in the endoscopy unit). • Include in your policy and procedures remote access protocols, on-/off-site information storage practices, and employee exit strategies. • Identify procedures for the use of organizational and personal mobile devices within the perioperative care environment. • In an ambulatory surgery center, designate a person to oversee protection of clinical records. • Enter any medical advice given to a patient via text, e-mail, or telephone in the patient’s clinical record; sign and date the entry. Controlling access to the patient’s health information prevents privacy and security breaches for entities covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Authentication identifies the author of the documentation entry and indicates responsibility for the interventions performed and patient information collected.
274 | AORN Journal
September 2017, Volume 106, No. 3
AUTHENTICATION AND MODIFICATION • Validate the original source authenticity and accuracy of transmitted information and evaluate content for potential corruption. • Comply with your information policies for sharing electronic patient information. • Use an authentication process at the completion of the documentation process (eg, electronic signature, a pen-to-paper signature, rubber stamp signature, counter signature). • Include a signed consent from the patient for release of information in the health care record. • Retain the patient care record in the original or a legally reproducible format for the minimum allocation of time dictated by federal regulations and state statutes of limitations. • Make corrections, amendments, and addendums in paper records by: - placing a single line through the incorrect entry, being careful not to obliterate the inaccurate information - writing “error,” “mistaken entry,” or “omit” next to the incorrect text as determined by organizational policy - providing the rationale for the correction above the inaccurate entry if room is available or adding it to the margin of the document - signing and dating the entry - entering the correct information in the next available space or adjacent to the acknowledged inaccurate information • Make deletions and retractions of content from a closed electronic health record system according to organizational policies and procedures and the functionality of the information system. Authentication identifies the author of the documentation entry and indicates responsibility for the interventions performed and patient information collected. Corrections, clarifications, or changes to existing entries in the patient health care record should be made when necessary to accurately represent the patient’s care.
www.aornjournal.org
NURSING WORKFLOW
• Record in the patient’s health care record: - assessment findings (eg, physical, psychosocial, cultural, spiritual) - clinical problems - communication with other health care professionals - communication with and education of the patient - patient care orders, order acknowledgment, implementation, and management - nursing interventions performed, the time performed, the location of care, and the person performing the care - expected and interim patient outcomes - reassessment findings - local, state, and national regulatory requirements - mandatory reporting criteria for quality performance reimbursement - data important to ongoing and transitional care
• Synchronize perioperative nursing documentation with the nursing workflow. • Facilitate data capture using a format designed to support clinical workflow activities and eliminate redundancy in data entry.
• Collect and record patient data concurrently with each assessment, reassessment, or evaluation. The perioperative patient health care record reflects the plan of care and evaluation of progress toward the desired outcome.
272 | AORN Journal
• Evaluate perioperative electronic documentation systems for their ability to accommodate the objectives of the health care facility. Clinical information systems should address: - clinical workflow - patient safety - information needs of the patient care environment - patient population characteristics - clinician and provider usability requirements • If used, charting by exception processes should be formatted and reviewed by the health care organization’s risk management and legal representatives. Effective information systems collect, store, and organize patient information to allow real-time updates, support clinical decision making, and be accessible to health care professionals when needed. http://dx.doi.org/10.1016/S0001-2092(17)30709-3 © AORN, Inc, 2017 www.aornjournal.org
September 2017, Volume 106, No. 3
Guideline at a Glance
• Tailor patient health information to allow for the collection of unique patient care data (eg, communicable diseases, responses to medications, psychosocial considerations) that may affect the planned operative or other invasive procedure. • When using standing orders or preprinted order sets, do not use unacceptable abbreviations, eliminate trailing zeros in medication dosages, use standardized names and terms, and have the surgeon review for accuracy.
STRUCTURED VOCABULARY • Use a structured vocabulary (eg, the Perioperative Nursing Data Set [PNDS]) that is inclusive of the nursing process workflow and represents each phase of the perioperative patient care continuum (ie, preadmission, preoperative, intraoperative, postoperative). • Incorporate nursing process workflow and require unambiguous representation of the patient experience in each phase of perioperative nursing documentation. • Implement a documentation system that includes the PNDS and a standardized perioperative electronic framework. • Incorporate the standardized clinical terminologies identified by the US government to promote interoperability of health care data. A structured vocabulary describes patient care using controlled (ie, standardized) and unambiguous terms that are interpreted with consistent meaning among health care clinicians. PROFESSIONAL AND REGULATORY COMPLIANCE • Enter patient care orders into the clinical documentation system as close as possible to the time the order is communicated or the intervention is initiated. • Document verbal orders when they are communicated and verify them using a readback process that involves the ordering health care practitioner. • Record the names and roles of individuals participating in the patient’s perioperative care, as well as those not directly involved in the scheduled surgical or procedural intervention.
www.aornjournal.org
Patient care information collected and entered into the health care record is a tool for monitoring and evaluating the patient’s health status and response to care, a resource for evaluating compliance with regulatory requirements, and a method for aligning provision of services for reimbursement.
INFORMED CONSENT • Include in your documentation a complete and accurate informed patient consent for each surgical or invasive procedure to be performed. Include: - the name of the health care facility providing the surgery or invasive procedure - the specific name of the intervention to be performed - indications for the proposed intervention - the name of the responsible health care provider performing the intervention - risks and benefits associated with the proposed intervention - discussion of the risks and benefits with the patient or patient’s legal representative - the signature of the patient or the patient’s legal representative - the date and time the patient or the patient’s legal representative signed the informed consent document
AORN Journal | 273
Guideline at a Glance
- the date and time and the signature of the person who witnessed the patient or patient’s legal representative signing the informed consent document - the signature of the responsible health care provider who executed the informed consent discussion with the patient or patient’s legal representative - additional information required by state statutes or administrative rules, which may include other persons present in the procedure room (eg, assistant surgeon, medical residents, RN first assistant) The informed consent process must be documented for procedures and treatments that are identified in the health care facility’s medical staff policies as requiring informed consent. The patient or the patient’s legal representative is entitled to participate in the informed decisionmaking process, including the right to request or refuse treatment. ACCESS • Limit access to patient health information to authorized individuals based on the health care role (eg, surgeon, RN, perfusionist), responsibility, and function (eg, postanesthesia care unit RN assisting in the endoscopy unit). • Include in your policy and procedures remote access protocols, on-/off-site information storage practices, and employee exit strategies. • Identify procedures for the use of organizational and personal mobile devices within the perioperative care environment. • In an ambulatory surgery center, designate a person to oversee protection of clinical records. • Enter any medical advice given to a patient via text, e-mail, or telephone in the patient’s clinical record; sign and date the entry. Controlling access to the patient’s health information prevents privacy and security breaches for entities covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Authentication identifies the author of the documentation entry and indicates responsibility for the interventions performed and patient information collected.
274 | AORN Journal
September 2017, Volume 106, No. 3
AUTHENTICATION AND MODIFICATION • Validate the original source authenticity and accuracy of transmitted information and evaluate content for potential corruption. • Comply with your information policies for sharing electronic patient information. • Use an authentication process at the completion of the documentation process (eg, electronic signature, a pen-to-paper signature, rubber stamp signature, counter signature). • Include a signed consent from the patient for release of information in the health care record. • Retain the patient care record in the original or a legally reproducible format for the minimum allocation of time dictated by federal regulations and state statutes of limitations. • Make corrections, amendments, and addendums in paper records by: - placing a single line through the incorrect entry, being careful not to obliterate the inaccurate information - writing “error,” “mistaken entry,” or “omit” next to the incorrect text as determined by organizational policy - providing the rationale for the correction above the inaccurate entry if room is available or adding it to the margin of the document - signing and dating the entry - entering the correct information in the next available space or adjacent to the acknowledged inaccurate information • Make deletions and retractions of content from a closed electronic health record system according to organizational policies and procedures and the functionality of the information system. Authentication identifies the author of the documentation entry and indicates responsibility for the interventions performed and patient information collected. Corrections, clarifications, or changes to existing entries in the patient health care record should be made when necessary to accurately represent the patient’s care.
www.aornjournal.org