CONTINUING EDUCATION Guideline Implementation: Patient Information Management

1.4 www.aornjournal.org/content/cme

JENNIFER L. FENCL, DNP, RN, CNS, CNOR

Continuing Education Contact Hours Accreditation indicates that continuing education (CE) contact hours are AORN is accredited as a provider of continuing available for this activity. Earn the CE contact hours by education by the American Nurses Credentialing Center’s reading this article, reviewing the purpose/goal and objectives, Commission on Accreditation. and completing the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. A score Approvals of 70% correct on the examination is required for credit. This program meets criteria for CNOR and CRNFA recerti- fi Participants receive feedback on incorrect answers. Each cation, as well as other CE requirements. applicant who successfully completes this program can AORN is provider-approved by the California Board of fi immediately print a certi cate of completion. Registered Nursing, Provider Number CEP 13019. Check Event: #16541 with your state for acceptance of this activity Session: #0001 for relicensure. Fee: For current pricing, please go to: http://www.aornjournal Conflict-of-Interest Disclosures .org/content/cme. Jennifer L. Fencl, DNP, RN, CNS, CNOR, has no declared affiliation that could be perceived as posing a potential conflict The contact hours for this article expire December 31, 2019. of interest in the publication of this article. Pricing is subject to change. The behavioral objectives for this program were created by Liz Cowperthwaite, BA, senior managing editor, and Helen Starbuck Purpose/Goal Pashley, MA, BSN, CNOR, clinical editor, with consultation from fi To provide the learner with knowledge speci c to implementing Susan Bakewell, MS, RN-BC, director, Perioperative Education. “ ” the AORN Guideline for patient information management. Ms Cowperthwaite, Ms Starbuck Pashley, and Ms Bakewell have no declared affiliations that could be perceived as posing potential fl Objectives con icts of interest in the publication of this article. 1. Discuss the importance of documenting accurate and Sponsorship or Commercial Support complete patient information. No sponsorship or commercial support was received for this 2. Explain important features for a documentation platform. article. 3. Identify risks associated with a poorly designed documen- tation platform. Disclaimer 4. Describe the advantages of using standardized vocabularies. AORN recognizes these activities as CE for RNs. This 5. Discuss documentation requirements related to patient care recognition does not imply that AORN or the American orders. Nurses Credentialing Center approves or endorses products 6. Describe considerations for the security of patient records. mentioned in the activity.

http://dx.doi.org/10.1016/j.aorn.2016.09.020 ª AORN, Inc, 2016 566 j AORN Journal www.aornjournal.org Guideline Implementation: Patient Information Management

1.4 www.aornjournal.org/content/cme

JENNIFER L. FENCL, DNP, RN, CNS, CNOR

ABSTRACT Clinical documentation captured in a patient’s record provides personnel with information that can be used to guide patient care. Data collected in electronic health records can be accessed and aggregated across the health care delivery system to enhance the safety, quality, and efficacy of care. The updated AORN “Guideline for patient information management” provides guidance to perioperative personnel on documenting and managing patient information. This article focuses on key points of the guideline, which address data capture that supports the clinical workflow, incor- poration of professional guidelines and standards as well as regulatory and mandatory reporting elements, use of standardized clinical terminologies, data aggregation for use in research and analytics, considerations for patient care orders, and safeguards for the patient’s security and confidentiality. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures. AORN J 104 (December 2016) 566-577. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.09.020 Key words: patient information, clinical documentation, data management, structured data, perioperative orders.

he old nursing adage still rings true: If it is not robust systems for patient information management documented, it has not been done. Nursing that provide the ability to incorporate the nursing education programs have historically emphasized assessment, Tthe importance of documenting accurate and complete clinical built-in patient safety mechanisms (eg, an alert notifying a information that reflects the holistic care provided to patients. provider of a potential drug-drug interaction or a contrain- What has changed is that clinical data can now be captured dication based on a patient’s allergy), electronically and used in new and meaningful ways. With the the ability to create reports and analyze data, changing landscape of health care focused on population the capacity to store data and integrate clinical data collected health and health care reform, clinical information docu- in a larger platform, and mented in the patient’s (EHR) offers safeguards for patient confidentiality.3 organizations a greater capacity to enhance the safety and quality of care, improve efficacy of care, and access and Regardless of the platform in which patient care information is aggregate information.1,2 Hallmarks of a comprehensive documented, the ability to capture patient data accurately, documentation platform include consistently, and reliably is essential to facilitate goal-directed http://dx.doi.org/10.1016/j.aorn.2016.09.020 ª AORN, Inc, 2016 www.aornjournal.org AORN Journal j 567 Fencl December 2016, Vol. 104, No. 6 care and allow for comparison of expected versus actual password or a computer being mapped to the wrong printer, outcomes.4,5 Nurse H has received several positive comments from the perioperative nurses regarding how prepared they felt and how “ The AORN Guideline for patient information manage- much they liked the new documentation system. Not only is ”6 ment was updated in July of 2016. AORN guideline she a super user for this new EHR, but Nurse H helped select documents provide guidance based on an evaluation of the and configure the documentation platform her team is now fi strength and quality of the available evidence for a speci c using to record perioperative patient care. subject. The guidelines apply to inpatient and ambulatory settings and are adaptable to all areas where operative and Eighteen months ago, Nurse H was asked to be one of the other invasive procedures may be performed. clinical leads to help select an EHR and develop how it would look and work in perioperative services. Although she was Topics addressed in the patient information management pleased to be chosen for this team, she was also concerned. guideline include using the to guide Nurse H had heard rumors about unsuccessful launches of fl documentation, synchronizing documentation with work ow, EHRs at other health care facilities in town. At their first using structured vocabularies, adhering to regulatory require- committee meeting, she and her colleagues discussed that ments and professional practice standards, maintaining the some nurses they knew at other hospitals disliked using security of patient information, and modifying existing records electronic documentation. Their concerns included that in ways that comply with regulations and practice guidelines. documenting took time away from patient care and that it was This article elaborates on key takeaways from the guideline hard to adapt from documenting on “three pages of paper” to document; however, perioperative RNs should review the using “17 different computer tabs.” The committee members complete guideline for additional information and for guid- agreed it was their responsibility to choose an easy-to-use, ance when writing and updating policies and procedures. well-organized, standardized platform to facilitate accurate documentation and that they would need to provide thorough Key takeaways from the AORN “Guideline for patient education for the nurses who would be using it. information management” include the following: The selection committee met with the vendors of various EHR Clinical documentation should facilitate data capture using a platforms under consideration to assess the available products. format designed to support clinical workflow activities. Nurse H was pleased to discover that all of the EHR platforms Perioperative must correspond to the team reviewed incorporated mandatory documentation local, state, and federal regulatory requirements and must requirements and measurement criteria for quality performance incorporate mandatory reporting criteria for quality perfor- reimbursement that the nurses had been struggling to capture mance reimbursement. consistently in paper documentation. Often-missed items in The health care documentation system must incorporate the paper documentation included patient and family education standardized clinical terminologies identified by the US and engagement, cultural variables, patient attributes and government to promote interoperability of health care data. status, and the unique identifiers for surgical implants. In Structured data collected using a standardized perioperative addition to incorporating federally regulated reporting re- electronic framework should allow for data aggregation and quirements, the systems could be configured to include the be extractable for use in research and analytics. reporting elements required by state and local statutes. Perioperative documentation must include all patient care orders given in the perioperative patient care setting. Nurse H quickly realized, however, that not every platform fi Patient information must be secure, be held con dential, mirrored the perioperative nurses’ workflow. For example, and be protected from unauthorized disclosure (Figure 1). while participating in a demonstration of one product, Nurse H questioned why the documentation tab The following scenario highlights the key takeaways and other was located in the middle of the intraoperative record section aspects of the AORN guideline. Each key takeaway is then when that is one of the first documentation elements a peri- discussed in detail after the scenario. operative RN would complete, and why the specimen ordering and documentation tab was located at the beginning of the SCENARIO EHR when most specimens are handed off the field after the The first week of implementation for the new integrated EHR surgery has begun. She realized how cumbersome and ineffi- at Central City Hospital had gone very well. Although there cient it would be to use such a system and the powerful effect were a few minor difficulties, such as someone forgetting a that the structure of the patient record format could have on

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Figure 1. Key takeaways from the AORN “Guideline for patient information management.” not only the workflow but on the accuracy of the informa- documentation requirements, incorporation of standardized tion captured. language, ability to build meaningful reports, and overall impression. After the committee made its decision, Nurse H The committee also discussed the importance of using became the head of a perioperative subcommittee to assess the common terminology in documentation that would promote chosen documentation platform and determine what, if any, consistency and reduce the possibility for ambiguity and changes they might need to make to ensure the system misunderstanding. All of the platforms they reviewed incor- complemented the perioperative workflow. porated standardized clinical terminologies identified by the US government to promote interoperability of health care Nurse H discovered that the ready-made product did not have data. At the previous year’s AORN Surgical Conference & a robust hand-over tool. Knowing that all patient care data Expo, Nurse H had attended a presentation on the importance important to ongoing care should be incorporated into the of standardizing vocabulary to allow for measuring the out- patient’s record, the subcommittee saw an opportunity to comes of the perioperative RN’s assessment, interventions, and reduce the potential for errors or omissions in communication evaluations of patient care. She suggested that the committee between clinicians. They worked with the shared governance choose a platform that also incorporated the Perioperative committee and the EHR vendor to develop hand-over tools Nursing Data Set (PNDS), a structured vocabulary inclusive for each phase of care (ie, short stay to the OR; OR to the of the nursing process workflow that allows for sharing postanesthesia care unit) and for shift changes (ie, shift-to-shift terminology related to each phase of perioperative care.7 reports) or RN relief periods that could be incorporated into the EHR. It was exciting for Nurse H and her team to realize The selection committee completed an evaluation of the this bigger picture of developing optimal documentation. Her different EHR platforms, assessing for congruence to work- organization would be able to take the best parts of the flow, ease of use, capture of mandatory (ie, federally regulated) ready-made product and work toward configuring those www.aornjournal.org AORN Journal j 569 Fencl December 2016, Vol. 104, No. 6 components that could enhance the current workflow. The assigned patient information; therefore, Nurse H helped end product would be a more accurate and consistent record develop education for the staff members to address the key of patient care. security measures to be implemented. Some of these included password access only, automatic log-off of the system after five Using standardized and structured data allows for aggregation minutes of inactivity, the inability to be in more than one of the data for research and analysis. The perioperative patient’s record at a time, and programs that would monitor subcommittee members were eager to begin planning how the for inappropriate viewing of a patient’s record. EHR could mine information from aggregated data and develop reports to help drive initiatives and quality improve- Before implementation, the nurses received education from ment processes in the organization. Some of the reports they both the EHR vendor and the subcommittee members, and they determined to be a priority included a surgical site infection participated in a simulated “go-live” to become familiar with the report, first procedure on-time starts, and an allograft docu- system before the official launch. As the first week of imple- mentation compliance report. The team understood that mentation came and went, Nurse H reflected on the experience these reports could help identify trends, monitor progress, of selecting and building an EHR for her organization, and was identify process improvement opportunities, and facilitate the very satisfied with the work she and her colleagues had done. development of action plans to appropriately address any identified concerns. KEY TAKEAWAYS DISCUSSION The key takeaways from the AORN “Guideline for patient Nurse H also recognized that the transition from a paper to an information management” address data capture that supports electronic record would provide an opportunity to address the the clinical workflow, incorporation of professional guidelines problem of nurses following orders from preference cards that and standards as well as regulatory and mandatory reporting were not regularly reviewed and might be outdated. The elements, application of standardized clinical terminologies, ’ preference cards highlighted the surgeon s orders for the data aggregation for use in research and analytics, inclusion of procedure, such as whether a urinary catheter is needed or patient care orders, and safeguarding the patient’s information fi what type of local medication to have on the eld, but there security and confidentiality. These takeaways do not cover the was not a system in place to ensure that these were kept up to entire guideline. Rather, they help the reader focus on fi date and regularly veri ed by the physician. In addition, many important or new information that should be implemented of the existing preference cards used unacceptable abbrevia- into perioperative practice. tions and did not use standardized terms for medications and instruments. Understanding the potential patient safety Clinical Documentation and Workflow concerns of using outdated preference cards, Nurse H took Perioperative RNs use the nursing process to critically this opportunity to discuss with her team the importance of assess every surgical patient and determine the appropriate placing all orders into the EHR, including those that were interventions needed to provide safe care during the surgical currently included on manual preference cards. She received experience.4-6,8,9 The elements of the nursing process that some pushback from perioperative RNs and physicians that provide a framework for documentation include assessment, “this is the way we have always done it.” She understood her , outcome identification, planning, imple- colleagues’ concerns but reminded them that established mentation of interventions, and evaluation of progress toward practice is not always best practice. She provided a near-miss expected outcomes.4-6,8-10 example of a patient who almost received the incorrect con- centration of heparin, almost three times the desired concen- A poorly designed documentation platform can contribute to tration, from a preference card that had not been updated in interruptions of clinical processes, incomplete or omitted years, to illustrate why this is such an important patient safety patient care information, and decreased nursing attention or issue. The subcommittee members ultimately concurred that it situational awareness.6,11,12 Therefore, regardless of the was imperative to have accurate orders in the perioperative documentation platform (ie, paper or electronic), it is crucial environment and agreed to incorporate all orders, including that patient care information be captured in a way that the preference card orders, into the EHR. All orders would be corresponds with clinical workflow activities to eliminate dated and timed, and authenticated by the ordering health care redundant data capture and inefficiencies.6,13-15 provider (ie, surgeon, anesthesiologist). In this scenario, Nurse H became aware of instances where an An important aspect of any EHR is establishing reliable EHR did not match clinical workflow and identified that this security so that only authorized care providers have access to could lead to patient care interruptions and patient harm. She

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Resources for Implementation What Else Is in the Guideline? Guideline implementation topics: information Read the AORN “Guideline for patient information management. AORN, Inc. http://www.aorn.org/guidelines/ management”1 to learn what the evidence says about guideline-implementation-topics/patient-care/information the following issues: -management. When should verbal orders be documented and how The AORN Syntegrity solution. http://www.aorn.org/ should they be verified? (Recommendation IV.b.4.) aorn-org/education/facility-solutions/aorn-syntegrity. What are the criteria for charting by exception? ORNurseLink. http://www.ornurselink.org/home. (Recommendation IV.e.2.) Perioperative Competency Verification Tools and Job What are some risk-reduction strategies to mitigate Descriptions [USB drive]. Denver, CO: AORN, Inc; potential patient record access violations? 2016. http://www.aorn.org/guidelines/clinical-resources/ (Recommendation V.a.1.) publications/document-collections/perioperative-competency What should policies for sharing of electronic patient -verification-tools-and-job-descriptions. information include? (Recommendation V.b.) Policy and Procedure Templates [CD-ROM]. 4th ed. What should the authentication process for patient Denver, CO: AORN, Inc; 2015. http://www.aorn.org/ health care records include? (Recommendation V.c.1.) guidelines/clinical-resources/publications/document How should patient care records be modified when -collections/policy-and-procedure-templates corrections, amendments, or addendums are needed? Editor’s note: Syntegrity is a registered trademark and (Recommendation VI.) ORNurseLink is a trademark of AORN, Inc, Denver, CO. Reference Web site access verified September 27, 2016. 1. Guideline for patient information management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: e1-e26. and her perioperative subcommittee also identified a need in the chosen EHR platform that led them to configure the product and create hand-over tools to promote standardization reporting requirements that the team had been struggling of critical patient care communications. to consistently capture with paper documentation.

Regulatory and Mandatory Reporting Standardized Clinical Terminologies Requirements By adopting standardized vocabularies, perioperative RNs have The patient record should not only reflect the care delivered the ability to uniformly document the care they provide in an during the surgical experience and the patient’sresponsebut unambiguous manner that can be consistently interpreted by 6,20,21 also show compliance with regulatory requirements, health health care clinicians. Nurse H convinced the selection care accreditation measures, national practice standards, and committee to choose a platform that incorporated the PNDS, fi mandatory reporting criteria for quality performance reim- a standardized nursing language speci c to perioperative 7,22 bursement.6,16-18 Current health care initiatives focus on nursing. Integration of the PNDS into the EHR fi health care reform, improved population health, public incorporates important elements of the nursing process speci c reporting of outcomes, transparency of data, and harnessing to perioperative care and demonstrates the unique contribu- 6,7,20,22 of health data to improve the quality of care delivered while tion of perioperative nursing to patient care. The reducing overall cost of health care.19 With publicly reported PNDS allows the perioperative RN to capture assessments, data, patients have the ability to make informed decisions interventions, and outcomes grounded in professional stan- fl about where to receive their care, organizations can evaluate dards re ective of clinical practice guidelines. Using an EHR the quality of patient outcomes and identify opportunities system with a comprehensive documentation framework for improvement, and value-based care versus volume-based ensures the appropriate integration of the PNDS and other care is supported.19 This necessitates that clinical docu- standardized languages and vocabularies. mentation systems be built to capture key data elements mandated by law for public reporting (eg, surgical site Data Aggregation and Analysis infection rates for targeted surgeries). In this scenario, the Using standardized and structured vocabularies facilitates data new EHR would facilitate mandatory documentation and aggregation and analysis to evaluate clinical processes and www.aornjournal.org AORN Journal j 571 Fencl December 2016, Vol. 104, No. 6 allows for integration of data into larger platforms In this scenario, to help secure the electronic patient record, (eg, repositories, registries) for comparing the effectiveness of several key measures were implemented to restrict access to the care practices among health care organizations.6,23-26 Data that patient’s information to authorized clinicians only. These are incorporated into larger data sets24,27 can be used in security measures included password access, an automatic predictive analytics and preventive models to improve the log-off of the system, the inability to open more than one quality, efficiencies, and outcomes of the health care delivery patient’s record at a time, and monitoring for inappro- system.24,27 The perioperative subcommittee realized the priate viewing. significance of aggregating data and developed several reports to drive initiatives and quality improvement processes in their CONCLUSION facility, such as reports to identify trends (eg, a surgical site Health care organizations should have robust systems for fi infection report), monitor progress (eg, rst procedure on-time patient information management that will allow clinical data starts), and identify process opportunities (eg, allograft docu- to be captured and applied in new and meaningful ways. mentation compliance). Essential to creating a comprehensive documentation plat- form that reflects the individualized care delivered in the Patient Care Orders perioperative setting is for the perioperative RN to know and A patient care order reflects the physician’s directives on his or understand best practices related to patient information her plan of medical care for the patient.28,29 The Centers for management. Perioperative RNs should proactively engage in Medicare & Medicaid Services require patient care orders to be practices to best align clinical documentation with the patient fl documented, dated, timed, and authenticated by the ordering care work ow, incorporate standardized clinical language and fl health care provider (ie, surgeon, anesthesiologist).6,28,30-32 discrete data elements into documentation, re ect profes- This includes any verbal order, standing order, or order listed sional guidelines and standards in documentation elements, fi on surgeon preference cards.6 When patient care orders are record all orders, and maintain security and con dentiality of not documented, dated, timed, and authenticated by the patient records at all times. By having a thorough under- ordering health care provider, there is risk for error and patient standing of best practices related to patient information harm. For example, patients may be at risk if preference cards management, perioperative RNs can promote the use of contain outdated, incomplete, or erroneous information.6,30-32 documentation platforms that provide vital information for organizations to improve population health and care de- In this scenario, there was no consist system in place to review livery outcomes. and update preference cards. Realizing that this posed a potential patient safety concern, Nurse H emphasized the importance of this issue and shared recent research evidence References practice with the perioperative subcommittee. The team 1. Management of Patient Information: Trends and Challenges in d agreed to incorporate the orders currently on the preference Member States. Global Observatory for eHealth series Volume 6. Geneva, Switzerland: World Health Organization; 2012. http:// cards into the EHR. apps.who.int/iris/bitstream/10665/76794/1/9789241504645_eng .pdf. Accessed September 27, 2016. Security 2. What are the advantages of electronic health records? HealthIT .gov. https://www.healthit.gov/providers-professionals/faqs/what Health care providers and organizations are obligated to pro- -are-advantages-electronic-health-records. Accessed September fi tect patient con dentiality by disclosing patient information 27, 2016. only to those directly involved in the patient’s care or those the 3. Galvez JA, Rothman BS, Doyle CA, Morgan S, Simpao AF, patient identifies as able to receive the information.6,33,34 The Rehman MA. A narrative review of meaningful use and Health Insurance Portability and Accountability Act of 1996 is information management systems. Anesth Analg. 2015;121(3): the federal law mandating health care organizations and 693-706. clinicians to safeguard patient’s medical information.6,33,34 4. Standards of perioperative nursing. In: Guidelines for Perioperative This law was updated in 2009 to correspond with the Practice. Denver, CO: AORN, Inc; 2015:693-708. 5. ANA Principles for Nursing Documentation. Silver Spring, MD: Health Information Technology for Economic and Clinical American Nurses Association; 2010. Health Act to include security standards for protecting 6. Guideline for patient information management. In: Guidelines for electronic health information. The health care organization is Perioperative Practice. Denver, CO: AORN, Inc; 2016:e1-e26. legally responsible for establishing procedures to prevent 7. Petersen C, ed. Perioperative Nursing Data Set. 3rd ed. Denver, data breaches. CO: AORN, Inc; 2011.

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8. Nursing: Scope and Standards of Practice. Silver Spring, MD: 23. Medicare and Medicaid programs; Electronic Health Record American Nurses Association; 2010. Incentive Programdmodifications to meaningful use in 2015 9. Peterson AM. as a legal document part 2: meeting through 2017; proposed rule. 80(72) Fed Regist. (April 15, 2015) the standards. J Leg Nurse Consult. 2013;24(1):4-10. 20346-20399 (codified at 42 CFR x495). 10. The nursing process. American Nurses Association. http://www 24. Murdoch TB, Detsky AS. The inevitable application of big data to .nursingworld.org/EspeciallyforYou/StudentNurses/Thenursing health care. JAMA. 2013;309(13):1351-1352. process.aspx. Accessed September 27, 2016. 25. Transforming Health Care Through Big Data. New York, NY: 11. Ash JS, Berg M, Coiera E. Some unintended consequences of Institute for Health Technology Transformation; 2013. information technology in health care: the nature of patient care 26. Sun J, Hu J, Luo D, et al. Combining knowledge and data driven information system-related errors. J Am Med Inform Assoc. 2004; insights for identifying risk factors using electronic health records. 11(2):104-112. AMIA Annu Symp Proc. 2012;2012:901-910. 12. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of 27. Al-Rawajfah OM, Aloush S, Hewitt JB. Use of electronic health- information technologies in health caredan interactive socio- related datasets in nursing and health-related research. West J technical analysis. J Am Med Inform Assoc. 2007;14(5): Nurs Res. 2015;37(7):952-983. 542-549. 28. State Operations Manual Appendix AdSurvey Protocol, 13. Gugerty B, Maranda MJ, Beachley M, et al. Challenges and Regulations and Interpretive Guidelines for Hospitals. Rev. 151. Opportunities in Documentation of the Nursing Care of Patients. Centers for Medicare & Medicaid Services. Department of Baltimore, MD: Maryland Nursing Workforce Commission, Health and Human Services. https://www.cms.gov/Regulations-and Documentation Work Group; 2007. -Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals 14. Lee S, McElmurry B. Capturing nursing care workflow disruptions: .pdf. Revised November 20, 2015. Accessed September 27, 2016. comparison between nursing and physician workflows. Comput 29. Blanchard TP. Physician orders. Presented at: Institute on Inform Nurs. 2010;28(3):151-159. Medicare and Medicaid Payment Issues; March 26-28, 2014; 15. Colligan L, Potts HW, Finn CT, Sinkin RA. Cognitive workload Baltimore, MD. https://www.healthlawyers.org/Events/Programs/ changes for nurses transitioning from a legacy system with paper Materials/Documents/MM14/gg_blanchard_slides.pdf. Accessed documentation to a commercial electronic health record. Int J Med September 27, 2016. Inform. 2015;84(7):469-476. 30. US Department of Health and Human Services. Condition of 16. US Department of Health and Human Services. Conditions of participation: medical record services. 42 CFR x482.24. https:// participation for hospitals. CFR x482. https://www.gpo.gov/fdsys/ www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title granule/CFR-2011-title42-vol5/CFR-2011-title42-vol5-part482/ 42-vol5-sec482-24.pdf. Published November 27, 2007. Accessed content-detail.html. Effective October 1, 2011. Accessed September September 27, 2016. 27, 2016. 31. Joint Commission. 2016 Comprehensive Accreditation Manual for 17. Scruth EA. Quality nursing documentation in the medical record. Ambulatory Care (CAMAC). Oakbrook Terrace, IL: Joint Commission Clin Nurse Spec. 2014;28(6):312-314. Resources; 2015. 18. US Department of Health and Human Services. Ambulatory sur- 32. Joint Commission. 2016 Comprehensive Accreditation Manual for gical centers (ASCs). 42 CFR x416. https://www.cms.gov/ Hospitals (CAMH). Oakbrook Terrace, IL: Joint Commission Regulations-and-Guidance/Legislation/CFCsAndCoPs/ASC.html. Resources; 2015. Published October 24, 2011. Effective December 23, 2011. 33. Health Insurance Portability and Accountability Act of 1996, 42 Accessed September 27, 2016. USC x201 (1996), Pub L No. 104-191, 110 Stat 1936. 19. Reform in action: can publicly reporting the performance of health 34. Modifications to the HIPAA privacy, security, enforcement, and care providers spur quality improvement? Robert Wood Johnson breach notification rules under the Health Information Technology Foundation. http://www.rwjf.org/en/library/research/2012/08/reform for Economic and Clinical Health Act and the Genetic Information -in-action--can-publicly-reporting-the-performance-of-heal.html. Nondiscrimination Act; other modifications to the HIPAA rules. Published August 2012. Accessed September 27, 2016. 78(17) Fed Regist. (January 25, 2013) 5565-5702 (codified at 45 20. H€ayrinen K, Lammintakanen J, Saranto K. Evaluation of electronic CFR x160, 45 CFR x164). nursing documentationdnursing process model and standardized terminologies as keys to visible and transparent nursing. Int J Med Inform. 2010;79(8):554-564. 21. Zielstorff RD. Characteristics of a good nursing nomenclature Jennifer L. Fencl, DNP, RN, CNS, CNOR, is a clinical from an informatics perspective. OnlineJIssuesNurs.1998; nurse specialist, Operative Services, and the interim 3(2). executive director of Clinical Support and Research at 22. Graling PR. Understanding perioperative nursing through PNDS. Cone Health, Greensboro, NC. Dr Fencl has no declared Adv Nurses. 2002;2(17):23. http://nursing.advanceweb.com/ affiliation that could be perceived as posing a potential Article/Understanding-Perioperative-Nursing-Through-PNDS.aspx. conflict of interest in the publication of this article. Accessed September 27, 2016.

www.aornjournal.org AORN Journal j 573 EXAMINATION Continuing Education: Guideline Implementation: Patient Information Management

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PURPOSE/GOAL To provide the learner with knowledge specific to implementing the AORN “Guideline for patient information management.”

OBJECTIVES 1. Discuss the importance of documenting accurate and complete patient information. 2. Explain important features for a documentation platform. 3. Identify risks associated with a poorly designed documentation platform. 4. Describe the advantages of using standardized vocabularies. 5. Discuss documentation requirements related to patient care orders. 6. Describe considerations for the security of patient records.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.

QUESTIONS 3. Aggregated data can help team members 1. A comprehensive documentation platform 1. identify process improvement opportunities. 1. can be used to create reports and analyze data. 2. identify trends. 2. can store and integrate data. 3. facilitate development of action plans. 3. has built-in safety mechanisms. 4. monitor progress. 4. incorporates the nursing assessment. 5. update preference cards. 5. safeguards patient confidentiality. a. 1 and 3 b. 2 and 5 a. 1 and 2 b. 2, 4, and 5 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5 c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5 4. A poorly designed documentation platform can con- tribute to 2. Capturing a patient’s data accurately, consistently, and 1. aggregation of data. reliably allows for comparison of 2. decreased nursing attention. a. expected outcomes versus actual outcomes. 3. increased situational awareness. b. nursing interventions versus surgical interventions. 4. interruptions of clinical processes. c. preference card orders versus verbal orders. 5. omitted patient care information. d. state regulatory requirements versus federal regulatory a. 1 and 3 b. 2, 4, and 5 requirements. c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5

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5. The patient record should show compliance with 8. The Centers for Medicare & Medicaid Services require 1. health care accreditation measures. that patient care orders be 2. mandatory reporting criteria for quality performance 1. authenticated by the ordering health care provider. reimbursement. 2. included on preference cards. 3. national practice standards. 3. dated. 4. regulatory requirements. 4. timed. a. 1 and 3 b. 3 and 4 a. 1 and 2 b. 3 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4

9. Verbal orders do not need to be documented. 6. By adopting standardized vocabularies, perioperative RNs a. true b. false have the ability to uniformly document the care they provide in an unambiguous manner that can be consis- 10. Health care providers and organizations are obligated to tently interpreted by health care clinicians. protect patient confidentiality by disclosing patient a. true b. false information only to those 1. directly involved in the patient’s care. 7. Integration of the Perioperative Nursing Data Set into the 2. directly or indirectly involved in the patient’s care. electronic health record incorporates important elements 3. who the patient identifies as able to receive the of the nursing process specific to perioperative care and information. demonstrates the unique contribution of perioperative 4. using patient information for research. nursing to patient care. a. 2 and 4 b. 1 and 3 a. true b. false c. 1, 2, and 4 d. 1, 2, 3, and 4

www.aornjournal.org AORN Journal j 575 LEARNER EVALUATION Continuing Education: Guideline Implementation: Patient Information Management

1.4 www.aornjournal.org/content/cme

his evaluation is used to determine the extent to CONTENT which this continuing education program met 7. To what extent did this article increase your knowl- your learning needs. The evaluation is printed edge of the subject matter? There for your convenience. To receive continuing education Low 1. 2. 3. 4. 5. High credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. 8. To what extent were your individual objectives met? Rate the items as described below. Low 1. 2. 3. 4. 5. High 9. Will you be able to use the information from this OBJECTIVES article in your work setting? To what extent were the following objectives of this 1. Yes 2. No continuing education program achieved? 10. Will you change your practice as a result of reading 1. Discuss the importance of documenting accurate and this article? (If yes, answer question #10A. If no, complete patient information. answer question #10B.) Low 1. 2. 3. 4. 5. High 10A. How will you change your practice? (Select all that 2. Explain important features for a documentation platform. apply) Low 1. 2. 3. 4. 5. High 1. I will provide education to my team regarding why change is needed. 3. Identify risks associated with a poorly designed docu- 2. I will work with management to change/imple- mentation platform. ment a policy and procedure. Low 1. 2. 3. 4. 5. High 3. I will plan an informational meeting with physi- 4. Describe the advantages of using standardized vocabu- cians to seek their input and acceptance of the laries. need for change. Low 1. 2. 3. 4. 5. High 4. I will implement change and evaluate the effect of the change at regular intervals until the change is 5. Discuss documentation requirements related to patient incorporated as best practice. care orders. 5. Other: ______Low 1. 2. 3. 4. 5. High 10B. If you will not change your practice as a result of 6. Describe considerations for the security of patient re- reading this article, why? (Select all that apply) cords. 1. The content of the article is not relevant to my Low 1. 2. 3. 4. 5. High practice.

576 j AORN Journal www.aornjournal.org December 2016, Vol. 104, No. 6 Guideline Implementation: Patient Information Management

2. I do not have enough time to teach others about 4. Other: ______the purpose of the needed change. 11. Our accrediting body requires that we verify the time 3. I do not have management support to make a you needed to complete the 1.4 continuing education change. contact hour (84-minute) program: ______

www.aornjournal.org AORN Journal j 577