Charting for Foot Care Nurses

Required Forms

• Medical Information Release form to help you get information from their primary care doctor or any of their other providers
• Acknowledge and Consent form
• Confidential Channel Communication Request
• Notice for bottom of letters and faxes
• Provider/Clinic Privacy Policy

Nursing documentation will fulfill one of more of the following four categories:

• Direct nursing skill
• Skilled observation and assessment
• Management of care plan
• Teaching and training activities

There are six items that nurses must document in order to accurately ensure patient and nurse safety, provide information and remain in compliance with HIPAA. These are:

1. Assessment
In your professional opinion, what are your initial feelings regarding the patient condition?

2. Nursing diagnosis and patient needs
Using what you know, how would you diagnose the patient and assess their needs?

3. Intervention
What steps did you take to intervene?

4. Care provided
What care was provided now and for the patient at home?

5. Patient response to care
Did you need to make adjustments to your treatment?

6. Patient ability to manage continuing care
Can the patient or someone caring for the patient manage his or her illness when at home?

Consider the following when creating your patient chart:

• Have you documented the subjective, the opinion your patient gives you?
• Have you documented the objective, what your observations are?
• Have you provided a clear assessment?
• Does your assessment include a plan?
• What does your intervention look like?
• When will you re-evaluate? Has re-evaluation taken place?
• Did you revise your plan?

If you didn't write it down, you didn't do it.

That's the importance of charting summed up in just one sentence. In this article, we'll explore the reasons for charting. These include the importance of patient and nurse safety, caregiver education, HIPAA compliance and communication.

As foot care becomes a more expansive field, nurses practicing foot care techniques are placed under increased scrutiny. We must prove that we can act independently and responsibly to provide only the care we are trained to provide. Charting is the only way to accomplish this.
Through your documented analysis, you'll be able to demonstrate the thought path which lead to your decisions and your plan of care. Keep in mind that the person reading your notes was not likely present at the time, so it's important to ensure you paint a picture with your words. All written entries must be easily understood by anyone to assure you're able to defend your decisions.

Whether you're in a private practice or a hospital, your actions must fall under HIPAA guidelines.

Because HIPAA is by far the most extensive reason why charting is so important, this article will focus mainly on this aspect.
Dr. Overstreet has provided a variety of resources for HIPAA. These include links to documents you will need such as a Privacy Policy.

A major portion of the Health Insurance Portability and Accountability Act deals with the transmission and safeguarding of documents. It is estimated that roughly 16% of privacy breaches occur from desktop use, 24% from laptop use, 14% from the use of portable electronic devices and 21% from paper. These breaches refer to the loss of personal information such as patient names, social security numbers, patient condition, payment information, birth dates and other identifying factors commonly referred to as Protected Health Information, or PHI.

In order to better safeguard patient information, HIPAA imposes strict limitations and guidelines for the transmission and keeping of patient records.

Electronic Transmission

PHI cannot be transmitted electronically, including via e-fax. PHI must be paper mailed, paper faxed or phoned in. Additionally, PHI should only be disclosed when the recipient of your call, letter or fax can reliably be identified. A confidentiality notice should appear at the bottom of any fax or authorized transmission form as a footer. Among a variety of other documents, you can find a confidentiality notice template here.

Physical Safeguards

You must limit physical access to charts and patient documents. Original files cannot be made available to other members of the healthcare community. You can however leave copies because these copies fall under their HIPAA compliance.
ePHIs are not permitted to leave the facility in any format.

Mobile Media

Mobile media such as smartphones, iPads, netbooks, thumb drives, and DVDs present a very high risk of exposure and require appropriate authorization. It should go without saying that PHI should never be shared on social networking sites or through chat or texting

If a breach occurs in your facility, it must be reported within 24 hours.

Signed Consent

While the privacy rule provides federal protection of personal information, it does not require you to get signed consent to share information for treatment purposes. You can fax, mail or phone other healthcare providers or family to share health information without your patient's consent.

*Although HIPAA does not state that you must, we believe it is always in everyone's best interest to openly communicate with your patients.

For more information about covered entities, check the link provided.