Foundations Ch. 15 Nursing Informatics

Why do we collect data?

Making an appropriate nursing diagnosis for our patient. Plan of care for our patients. Provide decision support. Enhance documentation. Identify nursing care trends and costs.

Ethical and Legal Concerns in Nursing Informatics

• Creation and retention of documents • Ownership of software • Ownership and integrity of data • Preservation of privacy and confidentiality • Prevention of computer fraud and misuse

Ten Commandments of Computer Ethics

1. Thou shalt not use a computer to harm other people 2. Thou shalt not interfere with other people's computer work. 3. Thou shalt not snoop around other people's computer files. 4. Thou shalt not use a computer to steal. 5. Thou shalt not use a computer to bear false witness. 6. Thou shalt not copy or use proprietary software for which you have not paid. 7. Thou shalt not use other people's computer resources without authorization or proper compensation. 8. Thou shalt not appropriate other people's intellectual output. 9. Thou shalt think about the social consequences of the program you are writing or the system you are designing. 10. Thou shalt always consideration and respect use a computer in ways that ensure for your fellow humans.

Nursing Minimum Data Set (NMDS)

in the delivery of care across settings, provide accurate descriptions of the nursing diagnoses, nursing care, outcomes of care, and nursing resources used.

Website Evaluation Criteria: Authority

patients their use of Who is the sponsor or publisher? Is this a personal page? Where does it come from? Is the author or organization listed? What are the author's credentials?

Decision Support System (DSS)

A computerized system that supports decision-making activities such as choosing appropriate diagnoses or medications and improving the quality of care through reminders and safe-practice alerts.

Electronic Health Record (EHR)

A longitudinal record of health that includes the information from both inpatient and outpatient episodes of health care from one or more care settings.

Website Evaluation Criteria: Coverage

Are citations correct? Is there a balance of text and images?

Website Evaluation Criteria: Accuracy

Are there footnotes or links to information sources?

Website Evaluation Criteria: Verification

Can the information be found in other sources?

Website Evaluation Criteria: Purpose

Does the site inform? Explain? Share? Disclose? Sell? What is the intended audience?

Data

Facts, observations, and measurements that can be used as a basis for reasoning, discussion, or calculation, but until they are organized and processed, data are meaningless.

Benefits of informatics

Helps us determine treatment decisions Helps us determine our nursing interventions Helps improve communication Helps to increase patient safety Helps keep errors down b/c of EMR Allows us to research patients conditions

Information

Is organized and processed data that can be communicated and are meaningful and useful to the recipient.

Knowledge

Is organized and processed information that can be applied to problem solving and decision making. The transformation of patient data to clinical information becomes nursing knowledge

Computerized Provider Order Entry (CPOE)

Orders are entered into a computer by clinicians and sent directly to the appropriate department.

Website Evaluation Criteria: Currency

When was the site created? How often is it updated?

ICNP

a standard terminology that provides a dictionary to describe and report nursing practice in a systematic way. This information supports care and decision making to inform nursing education, research, and health policy (ICN, The World Health Organization Family of International Classifications accepted ICNP as a related ter- minology in 2008.

A nurse manager has evaluated a new hire's informatics literacy and gave a rating of "beginner". What observations did the manager make to justify this rating? (Select all that apply.) a. Has adequate keyboarding skills. b. Documents well in the EHR. c. Understands data relationships. d. Conducts research using technology. e. Demonstrates skill in information management.

a. Has adequate keyboarding skills. b. Documents well in the EHR. The manager would have observed the nurse having adequate keyboarding skills and the ability to navigate through and document in the EHR. At the experienced level, the manager would note the ability to understand data relationships and skill in information management. Conducting research would be done by the innovator.

Information literacy

is the ability to recognize when information is needed and how it is produced and the ability use the needed information to locate, evaluate, and effectively to create new knowledge As the amount of available information increases exponentially, individuals must acquire the skills to select, evaluate, and use needed information.

Electronic Medical Record (EMR)

A record of one episode of care, either an inpatient stay or an outpatient appointment.

Define nursing informatics

A specialty area of informatics that addresses the use of health information systems to support nursing practice, by integrating nursing computer and information science for the management and communication or data, information, knowledge, and wisdom

Wisdom

Addresses the use of knowledge and experience to manage and solve problems. Wisdom is the appropriate application of knowledge. At the wisdom level, a nurse uses critical thinking to interpret and evaluate nursing knowledge.

Bar Code Medication Administration (BCMA)

After using a portable scanner to sign into the eMAR by scanning his/her identification badge, the nurse then electronically scans the bar codes on the patients wristband and on the drug to determine that the right patient is getting the right drug and dose at the right time. An alert on the eMAR signals a potential error, and it is the nurses responsibility to verify all information before administering the medication to the patient.

Data are best described as: a. organized information. b. facts, observations, and measurements. c. knowledge used to make decisions. d. the appropriate application of knowledge.

b. facts, observations, and measurements. Data are facts, observations, and measurements that can be used as a basis for reasoning, discussion, or calculation. Data are organized in a usable manner but this is not the best description.

Which description is true about the Nursing Minimum Data Set (NMDS)? a. An admission assessment tool b. A discharge summary c. The core nursing data for collection across all sites d. An organization of nursing diagnoses

c. The core nursing data for collection across all sites The NMDS is a standardized collection of essential nursing data used by nurses to promote consistent, understandable documentation. Although standard terminology may be used during admission and discharge, these tools are not a description of NMDS. Nursing diagnoses are organized using one of several taxonomies, including ICNP, CCC, and NANDA-I.

What is included in informative tools in health care?

Computers, guidelines, terminologies, information and communication systems

What are the benefits of nursing informatics?

Patient Safety Record Management Research Access Networking

True or False: "informatics is a very broad academic field"

True

The standard of how security and confidentiality of health care information must be maintained is determined by: a. NANDA-I. b. HIPAA. c. each health care facility. d. the Computer Ethics Institute.

b. HIPAA. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 sets the standards on how security and confidentiality of health care information must be maintained. Health care facilities may have additional guidelines to follow, but they do not set the standard. NANDA International has developed nursing terminology related to Nursing diagnoses. The Computer Ethics Institute has developed its own Ten Commandments of Computer Ethics, but they do not set the standard.

Which descriptions are advantages of health care information technology (IT)? (Select all that apply.) a. Increases health care delivery costs b. Improves communication among providers c. Improves administration functions d. Increases the potential for errors e. Decreases the safety of providing care

b. Improves communication among providers c. Improves administration functions Health care IT improves communication among providers by providing immediate access that is legible and standardized to patient data by all providers. IT improves administrative functions by addressing the issues of quality, cost-effectiveness, and outcomes of care. Although there are initial costs to purchase hardware and software, these systems are cost-effective in the long run. Systems that support data collection at the point of care can directly enhance patient care by decreasing the potential for errors, especially in interpreting handwriting, and supporting improved assessment and data communication.

Standardized nursing terminologies include: a. the ABC coding system. b. NANDA, NIC, and NOC. c. SNOMED-CT. d. ICD9 codes.

b. NANDA, NIC, and NOC. A standardized nursing terminology is a structured vocabulary that provides a common means of communication among nurses. A standardized language ensures that when a nurse talks about a specific patient problem, another nurse fully understands the problem. Standardized nursing terminologies recognized by the American Nurses Association include NMDS (nursing minimum data set), NMMDS (nursing minimum data set), CCC (clinical care classification), ICNP (international classification of nursing practice), NANDA-I (NANDA International), NIC (nursing interventions classification), NOC (nursing outcomes classification), Omaha System, and PNDS (perioperative nursing data set). ABC and SNOMED CT are examples of multidisciplinary terminologies. ICD-9 details terminology for billing and coding, not nursing.

Computer literacy

is knowledge of computers and the ability to use them efficiently. Computers are everywhere, and their applications continue to grow at an astounding rate.

Website Evaluation Criteria: Objectivity

What are the goals and objectives of the site? Is there evidence of bias? Is bias explicit or hidden?

Listserv

a computer program that automatically sends messages to multiple e-mail addresses on a mailing list. It can be used in health care to connect groups of patients with or to send updated information to large common problems groups.

Which are major areas to be addressed when evaluating a website? (Select all that apply.) a. Authority b. Purpose c. Popularity d. Verification e. Currency

a. Authority b. Purpose d. Verification e. Currency Website evaluation criteria include authority, purpose, coverage, currency, objectivity, accuracy, and verification. Popularity is not one of the criteria to use when evaluating a website.

Which behaviors are expected of the nurse at the experienced informatics competency level? (Select all that apply.) a. Collect accurate assessment data. b. Conduct informatics research. c. Group assessment data. d. Document data appropriately on the electronic health record (EHR). e. Integrate information science, computer science, and nursing science.

a. Collect accurate assessment data. c. Group assessment data. d. Document data appropriately on the electronic health record (EHR). The nurse at the experienced level of informatics competency can see data relationships and is able to collect and group data. The nurse is skilled in the use of computer technology and can document in the EHR. Conducting informatics research and integration of the sciences is the specialist level of informatics competency.

Which items are supported by point-of-care use of information technology? (Select all that apply.) a. More accurate documentation b. Direct access to diagnostic results c. Confidentiality d. Direct access to records by patients e. Access to medication profiles

a. More accurate documentation b. Direct access to diagnostic results c. Confidentiality e. Access to medication profiles Point-of-care use of information technology provides more accurate documentation because the nurse documents patient information in real time. Diagnostic results are immediately available to the nurse. Confidentiality is protected when the nurse documents at the bedside using a secure log-in and password. Medication profiles are available to the nurse at bedside. Patients do not have direct access to their medical records because these records are secured by log-ins and passwords accessible only to health care providers caring for each patient.

A famous rock star has just been admitted to Unit 12A after an automobile accident. A nurse on Unit 12B who is a fan of the musician uses the electronic health record (EHR) to find out how the patient is doing. Which is true regarding the use of a patient's EHR? a. Only staff caring for the patient should access this record. b. Permission from a supervisor is needed to read this record. c. The patient's record can be discussed with the nurse's co-worker. d. The nurse can call a friend who works at the local newspaper.

a. Only staff caring for the patient should access this record. Patient information should be accessed only by staff caring for that patient. Security codes are required for EHR access, and access of records can be monitored. Professional ethics should dictate the nurse's behavior, and only the records of patients being cared for should be accessed. A patient's record can be discussed only with those who are caring for the patient, and, because the nurse is not on the same unit, the records should not be accessed or discussed by that nurse. Health Insurance Portability and Accountability Act (HIPAA) laws prevent the discussion of private patient information with anyone outside of the team providing care.

Which activity by a unit nurse demonstrates information literacy? a. Researching a patient's diagnosis online b. Entering patient data into the electronic health record (EHR) c. Organizing patient data to study trends d. Learning a new electronic health record system

a. Researching a patient's diagnosis online The nurse is demonstrating information literacy (the ability to recognize when information is needed and to locate and use that information) when researching a patient's diagnosis online. Entering patient data into the EHR or learning a new EHR system demonstrates beginner nursing informatics competency. Organizing patient data to study trends demonstrates an experienced level of nursing informatics competency.

A nurse is studying ethics as they related to informatics. What actions does the nurse learn to be unethical? (Select all that apply.) a. Using proprietary software for which you have not paid b. Assuming a false identity on line c. Accessing patient's records d. Claiming another person's intellectual output e. Interfering with another's computer work

a. Using proprietary software for which you have not paid b. Assuming a false identity on line d. Claiming another person's intellectual output e. Interfering with another's computer work It is not ethical to use proprietary software for which you have not paid. It is not ethical to assume a false identity. It is not ethical to take another person's intellectual output and claim it as your own. And it is not ethical to interfere with another person's computer work. It is ethical to access your own patient's files for legitimate work purposes.

Which description is an example of data? a. A print-out of a patient's history and physical examination b. A patient's blood pressure and pulse rate c. The nurse's knowledge of a disease d. A nurse's interpretation of a change in the patient's condition

b. A patient's blood pressure and pulse rate Data are facts, observations, and measurements such as blood pressure and pulse rate. A printout of the patient's history and physical is organized information that is meaningful. Knowledge is organized and processed information such as a nurse's knowledge of a disease. When nurses interpret a change in the patient's condition, they are using wisdom or the use of knowledge and experience to manage and solve problems.

The hospital has implemented a new electronic medication administration record (eMAR). What is true about the use of this new tool? a. Verifies medication dosages b. Reduces medication administration errors c. Eliminates the need to count narcotics d. Requires a hard copy of the MAR to be printed

b. Reduces medication administration errors The electronic medication administration record (eMAR) reduces medication errors by requiring the nurse to scan the patient's identification band and the medication. Although the eMAR alerts the nurse to potential errors such as the wrong dose, it is the nurse's responsibility to verify all information before administration of a medication. Narcotic counts are still kept in the electronic system. A hard copy of the MAR is not necessary.

Social media includes such sites as: (Select all that apply.) a. HIPAA. b. Twitter. c. Facebook. d. LinkedIn. e. WebMD.

b. Twitter. c. Facebook. d. LinkedIn. Social media includes online technologies such as Facebook, Twitter, and LinkedIn, which allow people to communicate easily via the Internet to share information and resources. HIPAA stands for the Health Insurance Portability and Accountability Act and is not an example of social media. WebMD is an internet site with reputable medical information.

Information can be best defined as: a. organized and processed data that can be applied to problem solving and decision making. b. organized and processed data that can be communicated and are meaningful and useful to the recipient. c. the transformation of patient data to clinical information easily retrieved by others. d. the appropriate application of knowledge to improve patient care.

b. organized and processed data that can be communicated and are meaningful and useful to the recipient. Information is organized and processed data that can be communicated and are meaningful and useful to the recipient. Knowledge is organized and processed information that can be applied to problem solving and decision making. The transformation of patient data to clinical information becomes nursing knowledge. Wisdom addresses the use of knowledge and experience to manage and solve problems. Wisdom is the appropriate application of knowledge.

Information Literacy is best defined as the ability to do which of the following? (Select all that apply.) a. Access an electronic library. a. Understand data processing. b. Recognize when information is needed. c. Locate, evaluate, and effectively use needed information. d. Knowledge of computers and the ability to use them efficiently.

c. Locate, evaluate, and effectively use needed information. d. Knowledge of computers and the ability to use them efficiently. Information literacy is the ability to recognize when information is needed and to locate, evaluate, and effectively use the needed information. Computer literacy is knowledge of computers and the ability to use them efficiently. Understanding data processing and knowing how to access an electronic library are not the best definitions of information literacy.

Which statement is correct concerning the implementation of computerized provider order entry (CPOE)? a. The unit secretary transcribes the physician's orders into the computer. b. The nurse must ensure that orders go to the appropriate departments. c. Physician orders go directly to the appropriate department. d. Handwriting legibility is a major problem.

c. Physician orders go directly to the appropriate department. Use of CPOE enables orders to go directly to the appropriate department, decreasing the potential for errors. There is no transcription of orders and no need for someone to send the orders to the correct department. Because the orders are typed into the computer, handwriting legibility is not an issue.

The nurse is assigned to administer medications to a patient on a unit that has just implemented bar-code medication administration (BCMA). Which step is proper for the nurse to follow? a. Open the medication packages at the nurses' station. b. Ask the patient to verify his or her address. c. Scan the nurse's ID, the patient's ID, and the code on the medication package. d. Ask the patient to name two patient identifiers.

c. Scan the nurse's ID, the patient's ID, and the code on the medication package. The BCMA system scans the nurse's ID, the patient's ID, and the medication package to ensure that the proper drug is given to the correct patient. Asking the patient's address or two random identifiers that the patient may not be aware of would be inappropriate. Proper protocol for administration is to open the medication packages at the bedside. Use of a scanning device requires the medication to still be in the package while scanning to ensure that it is the proper medication.

A nursing job applicant is asked about his/her level of computer Literacy. What answer by the applicant shows the most computer literacy? a. "I can access an electronic library with ease." b. "I understand how the data gets processed. c. "I am able to locate, evaluate, and use information found electronically." d. "I have a working knowledge of computers and the ability to use them efficiently."

d. "I have a working knowledge of computers and the ability to use them efficiently." Computer literacy is knowledge of computers and the ability to use them efficiently. Information literacy is the ability to recognize when information is needed and to locate, evaluate, and effectively use the needed information. Understanding data processing and knowing how to access an electronic library are not the best definitions of computer literacy.

A global perspective on nursing practice might best be obtained from: a. NANDA, NIC, and NOC. b. ICD9 Codes. c. SNOMED-CT. d. ICNP.

d. ICNP. The International Classification for Nursing Practice (ICNP), developed under the auspices of the International Council of Nurses (ICN), provides a standard that facilitates the description and comparison of nursing practice locally, regionally, nationally, and internationally. NANDA, NIC, and NOC are examples of standardized nursing terminologies. SNOMED CT is an example of multidisciplinary terminology. ICD9 is used for billing purposes.

A listserv is best described as a/an: a. website that compiles health information. b. online library source for clinical research. c. blog concerning health care issues. d. program that sends messages to multiple e-mail addresses.

d. program that sends messages to multiple e-mail addresses. A listserv is a computer program that automatically sends messages to multiple e-mail addresses on a mailing list. Listservs can be used in health care to connect groups of patients with common problems or to send updated information to large groups.

standardized nursing terminology

is a structured vocabulary that provides a common means of communication among nurses. A standardized language ensures that when a nurse talks about a specific patient problem, another nurse fully understands the problem. An example is the choice among pressure injury, pressure ulcer, decubitus ulcer, and bedsore.