Once again, AHIMA steps up and provides a thorough source to guide the HIM professional on a host of documentation issues. Some of this information leads into next week’s content regarding storage of sensitive PHI.

The guidance for designated records is particularly timely as health technology expands the types of records flowing into the PHI data set. Digital x-rays, scans, and other diagnostics, interoperability that provides for a host of consult dictation becoming part of the record, home monitoring, telemetry monitoring, and a myriad of other documents must be addressed. Should they be included or is a narrative sufficient? If included where are they stored? How long are they stored? What exactly does the EHR include?

Photo Credit: https://www.smartsheet.com/medical-records-management

For years healthcare organizations have struggled to define their legal health records and align them with the designated record set required by the HIPAA privacy rule. Questions often arise about the differences between the two sets because both identify information that must be disclosed upon request.

The expanding scope of health records adds to the challenge of defining and compiling these record sets. An individual’s record can consist of a facility’s record, outpatient diagnostic test results or therapies, pharmacy records, physician records, other care providers’ records, and the patient’s own personal health record. Administrative and financial documents and data may be intermingled with clinical data.

In addition, the type of media on which information is recorded is also expanding. Source records may include diagnostic images, video, voice files, and e-mail. The organization must determine which of these data elements, electronic-structured documents, images, audio files, and video files to include.

The emergence of electronic health records (EHRs) also is complicating organizational efforts to define and disclose information. Information in EHRs is often stored in multiple systems, inhibiting the ability to succinctly pull together the record for either the legal health record or the designated record set.

These input systems may include laboratory information, pharmacy information, picture archiving and communications, cardiology information, results reporting, computerized provider order entry, nurse care planning, transcription, document imaging, and fetal trace monitoring systems, as well as a myriad of home-grown or individual clinical department systems.

However, the same criteria that organizations used to determine what paper records to retain and include in their legal health records and designated record sets can be applied to electronic records. Questions organizations must ask include:

What information can be stored long term?

What is clinically useful long term?

What is the cost of storage?

How can the organization effectively and succinctly assemble the EHR for long-term use?

This practice brief compiles and updates guidance from four previously published practice briefs to provide an overview of the purposes of the designated record set and the legal health record and helps organizations identify what information to include in each. It also provides guidelines for disclosing health records from the sets. The four original practice briefs are listed in the “Sources” section at the end of this practice brief.

Fundamentals of the Legal Health Record and Designated Record Set

Provide a plan for guidance for defining of electronic record health sets based upon AHIMA standards.

Include each of the following aspects in the assignment:

Ø  Access the AHIMA document: Fundamentals of the Legal Health Record and Designated Record Set

Ø  Create a chart with columns to place each of the five criteria to evaluate when defining what is part of the HER

Ø  Locate the five criteria in the middle of the document

1.  Identify Relevant Regulations, Standards, and Laws

2.  Determine Records Created in the Course of Business

3.  Address Retention Requirements

4.  Consider How Data Would Be Produced

5.  Classify External Records

Ø  Place each criterion in a column and list how you will define each

Ø  Submit your Word document chart to the drop-box

Ø  Cite the AHIIMA reference. APA is not required but as always proper grammar, sentence structure and spelling is expected. There is NO copy/pasting. Everything must be in your own words.

Nurse Recruitment and Retention Strategies

Given the present and upcoming necessity for nurses, healthcare administrations must concentrate on recruiting new nurses and retaining present nurses motivated in their clinical repetition. Comprehending how to keep nurses is a pressing issue that practically every healthcare company in the nation grapples with. Healthcare administrators are being challenged to look outside the box and investigate new nurse retention techniques to retain nurses. Some of the strategies that may be considered to improve staff nurse recruitment and retention include being strategic during recruitment, making career development a top priority, and offering a flexible work schedule. These strategies would be effective since employees contribute to improved patient eminence and abridged staff turnover when employees perform well and stay well. 

A targeted recruitment drive is an initial stage in building an effective nurse retention plan. With new graduating nurses accounting for a significant portion of general nursing turnover, recruiting the qualifying nurses from the beginning will make retention that much more straightforward. Recruiters, like nursing contenders, should strive to create an initial good impression through engaging them from the first touch. Another way of ensuring that one is strategic during recruitment is setting and meeting a hiring standard (Lasala 2017). While a contender’s submission will comprise a synopsis of their clinical repetition acquaintance and expertise, it will be less likely to contain their social abilities, which are important indicators of how composed they’ll fit into an organization. Assuring that an organization’s values and those of a nursing applicant are in sync encourages unity from the start. Responsibility, uprightness, and meticulousness are personality traits that can assist assess a contender’s behavioral qualities and probability of achievement in a particular position.

As noted earlier, another strategy that would be implemented to improve staff nurse recruitment and retention is making career development a top priority. More nurses seek additional degrees to take on innovative responsibilities in their professions, and nursing influential are garnering more respect than ever. Organizations must create a culture that encourages education and management growth to help nurses on their career paths (Yeager & Wisniewski 2017). A nurse’s capacity to care for their patients will be impacted by extra income. Still, continued improvement and medical training will also help them formulate decision-makers in the more incredible healthcare business. When considering how to boost nurse retention, organizations frequently neglect something as easy as identifying most performing nurses. Even a brief and unplanned party or remark at the morning cluster may support a nurse’s importance, refining their probability of remaining in their position. Idealistic nurse retaining must recognize those nurses with work centennials for their devotion and dedication to the business since they may be much comfortable with change.

The other strategy that would be recommendable is offering a flexible working schedule. Refining nursing staff retaining requires endorsing an excellent work-life balance. Nurses work long shifts that are both bodily and ardently taxing, leaving little space for extra energy. Organizations should foster a culture that supports time away from work and the opportunity to recharge, which is especially crucial for new nurse retention. This strategy can be achieved by reducing overtime work; Nurses who work overtime shifts regularly suffer from burnout, which lowers their assignation and gratification. Organizations that limit overtime work encourage the health of their nurses rather than focusing solely on the organization’s urgent operational demands, which benefits both in the long term. Employers may also consider a shared governance approach to scheduling. Nurses who have control over their schedule are more likely to feel powerful and confident in their work.

References

Lasala, K. (2017). Nursing workforce issues in rural and urban settings: Looking at the difference in recruitment, retention, and distribution. Online Journal of Rural Nursing and Health Care, 1(1), 8-24.

Yeager, V. A., & Wisniewski, J. M. (2017). Factors that influence the recruitment and retention of nurses in public health agencies. Public Health Reports, 132(5), 556-562.

REPLY 2

Nurse Retention

There are different nurse recruitment and retention strategies useful for employers to make the processes successful. The first one to consider is the need to foster a learning culture. Lifelong learning plays an essential role in achieving the required development in nursing (Efendi et al, 2019). The recruitment process and learning culture make the staff enjoy working at the institutions, thus leading to a high retention rate and increased quality of care.

On the same note, employers need to support career development as it is an important recruitment and retention strategy in nursing (Chhatre et al, 2018). The staff should be prepared for future roles and responsibilities. Leadership positions require one to have useful skills to unite employees and make the working environment conducive. The strategy is used by employers to ensure that nurses fill leadership positions in the field, thus high retention rate.

Similarly, hiring standards and behavioral competencies are considered by employers as a strategy for recruitment and retention goals (Efendi et al, 2019). The move targets to make nursing staff comfortable at their positions, thus increasing the quality of care. Behavioral competence is based on clinical skills together with technical ones. Teamwork and a positive attitude are examples of non-clinical skills that make working environments comfortable leading to a high retention rate. If a team can work as a unit, even the worst shifts can still have a positive environment. If the team does not function as such, everyday will be harder on the nurses as they feel overworked. This is what leads to burn out.

The strategies would be effective as employers aim to achieve organizational goals by making the working conditions favorable for the nurses. Employers focus on fostering a learning culture. It leads to individual development and improved quality of care (Chhatre et al, 2018). The same idea applies to the career development strategy used by employers to increase the retention rate. The establishment of a hiring standard and behavioral competency is useful at work. They ensure that nurses are comfortable at their respective positions and motivated accordingly to increase the retention rate.

References

Chhatre, S., Jefferson, A., Cook, R., Meeker, C. R., Kim, J. H., Hartz, K. M., … & Jayadevappa, R. (2018). Patient-centered recruitment and retention for a randomized controlled study. Trials, 19(1), 1-10. https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-2578-7 (Links to an external site.) 

Efendi, F., Kurniati, A., Bushy, A., & Gunawan, J. (2019). Concept analysis of nurse retention. Nursing & health sciences, 21(4), 422-427.https://onlinelibrary.wiley.com/doi/abs/10.1111/nhs.12629 (Links to an external site.) 

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