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HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 went into effect in the spring of 2003 to strengthen and protect patient privacy. Health care providers (e.g., physicians, nurses, nurse practitioners, physician assistants, pharmacies, hospitals, clinics, and nursing homes), health insurance plans, and government programs (e.g., Medicare and Medicaid) must notify patients about their right to privacy and how their health information will be used and shared. This includes information in the patient’s medical record, conversations about the patient’s care between health care providers, billing information, health insurers’ computerized records, and other health information. Employees must also be taught about privacy procedures.
In 2003, the Security Standards for the Protection of Electronic Protected Health Information were passed. More commonly known as the Security Rule, this is a federal regulation that more specifically requires health care organizations to protect the confidentiality, integrity, and availability of electronic patient health information (ePHI). This federal regulation extends to mandating that health care organizations establish technical safeguards for ePHI and regularly monitor the security of ePHI. In addition, it mandates that health care organizations be proactive in pursuing potential threats and resolving breaches in the security of ePHI.
Under HIPAA, patients also have the right to access their medical information, know when health information is shared, and make changes or corrections to their medical records. Patients also have the
right to decide if they want to allow their information to be used for certain purposes, such as marketing or research. Patient records with identifiable health information must be secured so that the records aren’t accessible to those who don’t have the authorization to view them.
Identifiable health information includes but is not limited to the patient’s name, Social Security number, identification number, birth date, admission and discharge dates, and health history.
right to decide if they want to allow their information to be used for certain purposes, such as marketing or research. Patient records with identifiable health information must be secured so that the records aren’t accessible to those who don’t have the authorization to view them.
Identifiable health information includes but is not limited to the patient’s name, Social Security number, identification number, birth date, admission and discharge dates, and health history.
ACCUCHARTDOCUMENTING PATIENT AUTHORIZATION TO USE PERSONAL HEALTH INFORMATION
Most facilities have an authorization form similar to the one shown here to be used for the release of a patient’s personal health information for reasons other than routine treatment or billing. The nurse should make sure all the required information is completed before having the patient or legal guardian sign the form.
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When patients receive health care, they need to sign an authorization form before protected health information can be used for purposes other than routine treatment or billing. The form should be placed in the patient’s medical record. (See Documenting patient authorization to use personal health information, p. 154.)
Essential Documentation
The nurse should use the agency’s HIPAA authorization form to document the patient’s consent for the use and disclosure of protected health information. An authorization form must include a description of the health information that will be used and disclosed, the person authorized to use or disclose the information, the person to whom the disclosure will be made, an expiration date, and the purpose for sharing or using the information. The form is to be signed by the patient or legal guardian and placed in the patient’s medical record.
HEARING IMPAIRMENT
Hearing loss occurs in varying degrees that range from the loss of only certain tones to total deafness. Hearing loss is most commonly classified by the cause of the impairment. Conductive loss results from the failure of sound waves to be transmitted through the external ear, middle ear, or both. Sensorineural loss results from pathologic changes in the inner ear, 8th cranial nerve, auditory centers of the brain, or all three. Mixed loss is a combination of conductive and sensorineural loss. Central hearing loss is a result of damage to the brain’s auditory pathways or auditory center. A gross or precise assessment can be done to determine the extent of the hearing loss.
Essential Documentation
The nurse should determine the length of time that the patient has had the hearing loss. Describe the patient’s degree of hearing loss and whether it is unilateral or bilateral. Note if the increased hearing loss is more significant in one ear. Record whether any hearing aids are being used. Include the effectiveness of hearing aids and the use of secondary modes of communication. Determine what additional methods are currently being used to compensate for the loss, such as lip-reading, sign
language, picture boards, or writing pads. Update the nursing care plan to reflect alternative forms of communication with the patient.
language, picture boards, or writing pads. Update the nursing care plan to reflect alternative forms of communication with the patient.
Hearing Impairment
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HEART FAILURE, DAILY ASSESSMENT
A syndrome characterized by myocardial dysfunction, heart failure leads to impaired pump performance (reduced cardiac output) or to frank heart failure and abnormal circulatory congestion. Congestion of the systemic venous circulation in right-sided heart failure may result in peripheral edema or hepatomegaly; congestion of the pulmonary circulation in left-sided heart failure may cause pulmonary edema, an acute, life-threatening emergency.
Although heart failure may be acute (as a direct result of myocardial infarction), it is generally a chronic disorder associated with the retention of sodium and water by the kidneys. Care for a patient with heart failure centers on symptom management, fluid balance, and prevention and management of complications.
Essential Documentation
The nurse should record the date and time of the entry. Record the patient’s subjective symptoms, such as shortness of breath, cough, activity intolerance, chest pain, orthopnea, and fatigue. Document the assessment of the respiratory system (adventitious breath sounds, use of accessory muscles, respiratory rate, pulse oximetry, and signs and symptoms of hypoxia) and cardiovascular system (jugular vein distention, abnormal heart sounds, heart rate, blood pressure, pallor, diaphoresis, cool, clammy skin, hemodynamic monitoring results, cardiac rhythm,
the degree and location of edema, urine output, and mental status). Include any new laboratory data, electrocardiogram (ECG) findings, and chest x-rays.
the degree and location of edema, urine output, and mental status). Include any new laboratory data, electrocardiogram (ECG) findings, and chest x-rays.
Record interventions, such as daily weight measurements, fluid restriction, intravenous (IV) therapy, and oxygen therapy, and record the patient’s response. Chart drugs given during the shift on the medication administration record. Daily intake and output are recorded on the intake and output record. (See “Intake and output,” pages 210 to 212.) Record patient education on such topics as energy conservation, disease process, nutrition, fluid restrictions, daily weights, drugs and other treatments, and signs and symptoms to report to the nurse or health care provider. Some facilities may use a patient education record to document any teaching provided (See “Patient teaching,” pages 293 to 298.)
Heart Failure
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HEAT THERAPY
Heat therapy is warmth applied directly to the patient’s body that raises the tissue temperature and enhances the inflammatory process by causing vasodilation and increasing local circulation. This promotes leukocytosis, suppuration, drainage, and healing. Heat therapy also increases tissue metabolism, reduces pain caused by muscle spasm, and decreases congestion in deep visceral organs. Moist heat softens crusts and exudates and penetrates deeper than dry heat.
Essential Documentation
The nurse should record the date and time of the application; the reason for the use of heat; the site of application; the type of heat used, such as dry or moist; the type of device, such as a K pad, chemical hot pack, or warm compresses; measures taken to protect the patient’s skin; and the duration of time the heat was applied. Include the condition of the skin before and after the application of heat therapy, signs of complications, and the patient’s response to the treatment. Record any patient education provided.
Heat Therapy
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HEMODYNAMIC MONITORING
Continuous pulmonary artery pressure (PAP) and intermittent pulmonary capillary wedge pressure (PCWP) measurements provide important information about left ventricular function and preload. This information is useful not only for monitoring but also for aiding diagnosis, refining assessment, guiding interventions, and projecting patient outcomes.
Nearly all acutely ill patients are candidates for PAP monitoring—especially those who are hemodynamically unstable, who need fluid management or continuous cardiopulmonary assessment, or who are receiving multiple or frequently administered cardioactive drugs. PAP monitoring is also crucial for patients with shock, trauma, pulmonary or cardiac disease, or multiorgan disease. It’s also used before some major surgeries to obtain baseline measurements.
Current pulmonary artery (PA) catheters have up to six lumens. In addition to distal and proximal lumens used to measure pressures, a balloon inflation lumen inflates a balloon for PCWP measurement, and a thermistor connector lumen allows for cardiac-output measurement. Some catheters also have a pacemaker wire lumen that provides a port for pacemaker electrodes and measures continuous mixed venous oxygen saturation.
The PA catheter is inserted into the heart’s right side with the distal tip lying in pulmonary capillary. Fluoroscopy may not be required during catheter insertion because the catheter is flow directed, following venous blood flow from the right heart chambers into the PA.
Essential Documentation
The nurse should document the date and time of catheter insertion. Include the name of the health care provider who performed the procedure. Identify the number of catheter lumens, the catheter insertion site, the pressure waveforms and values of the various heart chambers, and the balloon inflation volume required to obtain a wedge tracing. Note whether any arrhythmias occurred during or after the procedure.
Document any solution infusing through the catheter ports. Record the type of flush solution used and its heparin concentration (if any). Describe the type of dressing applied and the patient’s tolerance of the procedure. Chart all site care, dressing changes, tubing, and solution changes.
Hemodynamic Monitoring
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HOME CARE, HOME CARE AIDE NEEDS
Aides also provide respite to caregivers.
The registered nurse is responsible for developing the nursing care plan and supervising the home care aide’s activities in the patient’s home. Most agencies use a standard care plan or duty assignment sheet for this purpose that can be adapted to fit each patient’s needs.
To maintain state licensure and certification from The Centers for Medicare and Medicaid and The Joint Commission, the agency must require the home care aide to follow the patient’s care plan and to complete a separate home care aide note or entry in the patient’s clinical record for every visit.
Essential Documentation
On the home care aide assignment and care plan form, the nurse must itemize every activity that the aide is permitted to provide. This form may consist of a checklist of services and should include the date and time that the plan was initiated. (See Home care aide assignment care plan, page 161.) If the care plan was revised, this date and time must also be included. The patient’s name and identifying information, the health care providers name, the patient’s diagnosis, and short- and long-term goals are also included on the plan.
HOME CARE, INITIAL ASSESSMENT
After the registered nurse receives a referral and orders to begin home care, the nurse then needs to perform a thorough initial assessment of the patient and his or her home environment to set goals and tailor the care to the patient’s specific needs. Assessments vary slightly from agency to agency, but the basic information required for completion is the same.
The Conditions of Participation for Home Health Agencies requires that Medicare-certified agencies complete a comprehensive assessment of home care patients using a standardized data set called the Outcome and Assessment Information Set (OASIS). OASIS was developed specifically to measure outcomes for adults who receive home care. Using this instrument, the nurse collects data to measure changes in the patient’s health status over time. Typically, the nurse will need to collect OASIS data when a patient starts home care, at the 60-day recertification point, and when the patient is discharged or transferred to another health care facility, such as a hospital or subacute care facility. (See OASIS—Be careful when charting, page 162.) The OASIS data are collected using a
variety of strategies, including observation, interview, review of pertinent documentation when allowed (for example, hospital discharge summaries), discussions with other health care providers where relevant (for example, phone calls to the physician to verify diagnoses), and measurement (for example, intensity of pain).
variety of strategies, including observation, interview, review of pertinent documentation when allowed (for example, hospital discharge summaries), discussions with other health care providers where relevant (for example, phone calls to the physician to verify diagnoses), and measurement (for example, intensity of pain).
ACCUCHARTHOME CARE AIDE ASSIGNMENT CARE PLAN
The nurse should use this form to indicate the services to be performed and when the aide should perform them. Also communicate any special details of care on this form.
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Essential Documentation
The nurse should use the agency’s form to thoroughly and specifically document the assessment of the patient’s
nutritional status
home environment in relation to safety and supportive services and groups, such as family, neighbors, and community
knowledge of his or her disease or current condition, prognosis, and treatment plan and
potential for complying with the treatment plan
When completing the OASIS data set, the nurse will fill in or check off information on more than 80 topics, including:
sociodemographic data
physiologic data
OASIS—BE CAREFUL WHEN CHARTING
OASIS was first implemented in 1999 to measure outcomes in home health care. In October of 2000, the OASIS format changed because of the new Medicare payment system for home health care called the Prospective Payment System (PPS). What the nurse documents can have a significant impact on the services the patient receives and the reimbursement the agency collects. The OASIS format was revised again in January 2019 to simplify certification extensions, expand therapy visits, and increase the number of diagnoses that will be a case-mix diagnosis.
A point system is established for certain questions on the OASIS form, and it determines the reimbursement the agency will receive. For example, if the patient has had coronary artery bypass graft surgery and has two wounds, the nurse must document each wound in the appropriate areas of the OASIS form. Failure to document one or both of the wounds could potentially cost the agency a significant amount of money. Wounds are just one of the indicators that govern how much the agency will be reimbursed for patient care.
Problems can also occur when the nurse’s assessment on the OASIS form is inconsistent with the health care provider’s orders. For example, if the health care provider has ordered gait training and transfers but the nurse documents on the OASIS form that the patient can transfer and ambulate independently, the entire claim may be denied because physical therapy is not needed if the patient is independent.
These OASIS tools are used by Medicare to compare information and review claims. If the nurse has any questions about how to correctly answer OASIS questions in a given circumstance, the nurse should contact his or her supervisor or a continuous quality improvement nurse. Keep in mind that what the nurse documents has a significant impact on the patient and the agency. Read the questions carefully, and be sure of all answers. The nurse does make a difference!
functional data
service utilization data
admission source
mental, behavioral, and emotional data
process of care data
HOME CARE, INTERDISCIPLINARY COMMUNICATION IN
Communication between members of the home health care team is essential when caring for a patient at home. Ideally, the team works together toward similar goals to help the patient reach the expected outcomes. Agencies accomplish interdisciplinary communication in various ways. During patient care conferences, the team discusses the patient’s care plan and any changes needed in treatment. Between these conferences, team members may communicate with one another verbally, by email, text, or fax. However, the most important form of interdisciplinary communication is the agency’s interdisciplinary communication documentation. Surveyors place a great deal of emphasis on this documentation, which shows when, why, and by whom a care plan was changed. It clearly defines deviations from the original care plan. Because the information becomes part of the legal chart, the nurse should follow the guidelines for accurate documentation.
Essential Documentation
When completing interdisciplinary communication documentation, the nurse should be sure to fill in the following:
patient’s name and identification number
date and time
nurse’s name and title
name and title of the person to whom the information is being given or from whom the information is being received
subject matter discussed (e.g., abnormal laboratory results)
changes to the care plan as a result of this communication
name of team members notified of the change in the care plan
outcome of the conversation and any agreements made
actions taken
the nurse’s signature and title
When the nurse speaks to another member of the home health care team by phone, voicemail, email, text or fax, the same basic information should be documented.
ACCUCHARTINTERDISCIPLINARY COMMUNICATION FORM
Changes concerning the patient or changes to the care plan can be documented on the interdisciplinary communication form.
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HOME CARE, PATIENT-TEACHING CERTIFICATION IN
Patient and caregiver teaching are integral parts of almost every care plan. The most common goal is for the patient to have increased knowledge of his or her disease or treatment, and a standardized tool helps achieve that goal in an organized manner. Teaching checklists and certifications help to ensure that information is provided to the patient in a timely manner and in such a way that the patient’s and caregiver’s level of understanding can be easily evaluated. It also aids in interdisciplinary communication. Patient-teaching guides vary by agency, but the main content of the forms is the same.
Essential Documentation
The patient-teaching certification is a checklist that indicates that the instruction took place. Most documentation begin with the type of therapy or specific disease that will be taught. Then the patient’s comprehension level, motivational level, potential barriers to learning, knowledge of the disease or treatment, and skills are assessed. The patient’s anticipated outcomes are determined and documented, and the nurse tailors the care plan and teaching plan to the individual needs of the patient or caregiver.
If the agency does not possess a specific patient or caregiver teaching tool, the nurse should document this information in the nurse’s notes. Be sure to include all the previously mentioned information, and remember to document clearly on subsequent notes the patient’s or caregiver’s verbal and nonverbal communication regarding the procedures or instructions, their knowledge, and level of understanding.
Refer to Patient-teaching certification for an example of a completed form, page 166.
ACCUCHARTPATIENT-TEACHING CERTIFICATION
The model patient-teaching documentation here shows what was taught to a home care patient with an IV line in place. This type of documentation will help the nurse to document the teaching sessions clearly and completely.
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