Medical documentation/SŠ (nurse)

• Summary of information about the patient/client (P/K) of the medical facility maintained in any form.
• The terms data, data record and data carrier are different.
• Medical ZD = facts related to the provision of health care.
• Nursing ZD = facts regarding the provision of OSE care.
• Operational documentation = facts documenting the functioning of the operation.

Legal regulations

• Act No. 20/1966 Coll., Decree No. 385/2006 Coll. on medical documentation = basic legal regulations.
• Regulations for the archiving and disposal of personal data - Act on Archiving, Shredding Regulations of Health. Device.
• Act 101/2000 Coll. About the protection of documentation against misuse.
• Criminal Code §178 – penalties for unauthorized handling of personal data.

Mandatory confidentiality

• Given by law.
• The professional code stipulates the nurse's obligation to remain silent.
• The P/K Code of Rights sets out the P/K's right to expect that all information is confidential.
• Dg., th., facts related to P/K family, social affairs, occupation, religion and others.

Breach of Confidentiality

• The information that P/K is hospitalized in the ward is not protected by confidentiality.
• Breach of confidentiality is when a nurse discloses facts about P/K in society.
• Confidentiality is not breached when a telegram about the death of P/K is sent to the prescribed person.
• Violation is when the nurse gives information outside the ZZ to unauthorized persons.
• Breach of confidentiality is the negligent disclosure of medical information to unauthorized persons.
  • Sanctions for breach of confidentiality are based on the severity of the consequences.
  • The lawsuit is filed by P/K, the family, but also co-employees.
  • Monetary compensation according to §11 of the Civil Code.
  • Negligent act of unauthorized handling of personal data according to §178 of the Criminal Code.
  • Offense against civil coexistence.

Exemptions from mandatory confidentiality

• Communication between healthcare workers.
• Standard given in §67 b paragraph 13 of the Act on the Preservation of People's Health.

Contents of medical documentation

• P/K identification characters – name, surname, social security number, date of birth, place of residence.
• Identification signs of the medical facility – name of the facility, department, ID number (the same everywhere).
• Identification signs of the healthcare worker making the entry in the documentation – title, first and last name (stamped or printed) + signature.
• Medical history – RA, OA, PA, etc.

Documentation Management

• True and legible data, use of literary Czech.
• The data must be understandable.
• Dated addition of information with health identification.
• Time for important information (receipt, exit, etc.).
• Corrections authorized, original record must be legible.
• Substantiveness of records - indicates professional quality.
• The inspection is carried out by the SS, SS, the primary officer, the employee is responsible for the record, the SS at the station and the SS department is responsible for system errors in the documentation.

Do not use!!!

• Incorrect terminology.
• Slang expressions.
• Vulgarisms.
• Other language.
• Subjective feelings of the nurse.
• Unapproved abbreviations.

Purpose of medical records

• Serves to maintain continuity of care.
• It is proof of the care provided - proof of correctness of care → protection of health professionals.
• Document for accounting for care provided.
• Background for science and research.
• Storage and handling of documentation is governed by the regulations of the medical facility and department.
• Protection against misuse, loss or destruction is provided by ZZ - or The employee who takes over the ZD.
• Abbreviations must not be used, especially in relation to opiates.

Record of Addictive Substances

• Records of opiates.
• Numbered pages, as an attachment sample signatures of employees.
• Records should be written in blue, legibly – colored records intended for the receipt of substances and a record of the inspection carried out.
• Repairs authorized, do not paste, inform superior.

Consent to Performance

• Signature of the so-called positive reverse, consent of informed P/K.
• P/K does not give written consent to nursing care.
• Given Article 5 of the Convention on Human Rights and Biomedicine and §23, paragraphs 1 and 2 of the Act on People's Health Care - exceptions are listed in paragraphs 3 and 4.
• Other conditions are in §1 paragraph 2 of the decree on medical documentation - given situations when consent is necessary and when it is voluntary.
• The content and form are determined by the medical facility by internal regulation, but they have mandatory requirements:
• Purpose, nature, benefit, consequences and possible risks of performance.
  • Performance alternatives.
  • Restrictions in normal life and work ability, changes in health capacity.
  • Record of P/K statements.
  • Date and signature of P/K and healthcare worker.
  • Includes instruction on health status.
  • Gives consent to the procedure with regard to possible complications and the benefit of care - treatment.

Documentation in the operating room

• Medical records.
• Decurs.
• Nursing records.
• Informed consents.
• Radiological findings → completeness check, P/K identity verification.

Sleeping room

• Tracking FF.
• Pain monitoring.
• Fluid intake and output.
• Written assessment of the condition by the nurse.
• Doctor's office and their fulfillment.
  • → The doctor decides on discharge.
  • → The admission and discharge times + signatures are recorded in the documentation.

Links

References

• VONDRAČEK, Lubomír, et al. Nursing documentation in practice. 1. edition. Prague : Grada, 2003. 72 pp. ISBN 80-247-0704-7.