Chapter 15: Nursing Informatics

Future directions of informatics in nursing

Advancements in nursing informatics will enable nurses to improve patient care and safety, gather evidence of best practice, use point-of-care documentation and references, and advocate for consumer access to health care information.

Electronic Medical Record

An EMR is the documentation of a single episode of care such as an outpatient visit or inpatient stay. The EMR becomes part of an electronic health record (EHR), which is a longitudinal record of care. The EHR maintains the patient's health records over long periods. The EHR and not the EMR creates work lists on the basis of information in the database. The work list ensures timely administration of medication and response to specific interventions over the long term.

Implement the use of information technology in obtaining health information for consumers and in educating nurses

As the Internet becomes a widely used source of health information, nurses need to know how to evaluate websites and direct consumers to sites that are reliable.

Clinical Decision Support System

Based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user

Health of the Net Foundation

HON is an international initiative that focuses on the promotion and use of reliable online health information.

Telehealth/Telemedicine

Helps health care professionals to connect to health care experts or clinicians via high-quality video links. In an emergency, the nurse can enlist the help of a health care expert or clinician to provide emergency interventions to save a patient.

Information

Information helps in the analysis of a patient's past medical history and present health condition but is not sufficient on its own to manage and solve problems.

eHealth Code of Ethics

Is to ensure that people understand the potential risks of the Internet while managing health care.

Competency levels of nursing informatics

Levels of competency in nursing informatics are beginning, experienced, specialists, and innovator, and they determine specific roles of nursing. The nurse's role in the use of informatics intensifies as the competency level increases.

Listserv

Listserv is a computer program that is used to send health care emails to a large group of patients. STUDY TIP: Think of a listserv and a tool that serves a list of people. It helps them connect with each other and receive information.

Knowledge

Medical knowledge is processed and organized information that helps in critical thinking and clinical decision-making.

Discuss the uses of technology in health care

Mobile workstations, bedside computers and tablets, cell phones, pagers, iPods, fax machines, and personal digital assistants are used in health care for communication, reference, and documentation. Robots are used in operating rooms and pharmacies, x-rays are in digital form, and tele-health or telemedicine is used to link medical experts with other clinicians and to provide in-home monitoring of patients.

Summarize potential ethical issues related to the use of health care information technology

Nurses must be aware of potential legal and ethical issues related to computer applications in health care, such as patients' rights and protection of patients information.

Safe Practice Alert!

Nurses must ensure the accuracy of recorded data. Documentation should occur on a timely basis. Bedside and mobile computers enable real time charting.

Nursing informatics

Nursing informatics is a specialty area of informatics that addresses support of nursing practice in health information systems.

Health Insurance Portability and Accountability Act (HIPAA)

Sets standards on how security and confidentiality of health care information must be maintained. The act sets the penalties for any breach in security of health care data. The nurse practices safety while accessing an electronic health record system by using a sign-on and password code which is not shared with anyone. STUDY TIP: Notice the P in HIPAA stands for portability, but think of it as also standing for privacy. HIPAA sets the standards for how a person's private health information is shared or not shared.

Safe Practice Alert!

Technology at the point of care can provide the right data on the right patient at the right time

Clinical Care Classification

The CCC is a nursing terminology system that is used for documenting the plan of care in a health care setting. It includes documented information about the diagnosis, the plan for nursing interventions, and the effectiveness of the outcomes.

Ten Commandments of Computer Ethics

The Computer Ethics Institute (CEI) developed the Ten Commandments of Computer Ethics to manage ethical issues associated with the advancement of information technologies.

Perioperative Nursing Data Set

The PNDS is a set of nursing terminologies approved by the ANA for diagnoses, interventions, and outcomes for use in the perioperative area.

Benefits of informatics

The benefits include improved organization, communication, and information access; safer medication administration; reduction of duplicate orders and paperwork; better decision making; reduced charting time; improved administrative functions

Wisdom

The nurse uses wisdom to manage and solve problems by applying knowledge and experience. The nurse uses critical thinking to interpret patient assessment data and then evaluate patient priorities in the plan of care.

Importance of standardized terminologies in electronic health records

The use of standardized nursing terminologies supports the capture of important data and nursing information.

Nursing Intervention Classification

Used in the planning phase of the nursing process to document specific nursing interventions for a patient.

Bar-Code Medication Administration

Used to ensure that the right patient receives the right medication and dose at the right time.

International Classification for National Practice (ICNP)

Was developed under the auspices of the International Council of Nurses (ICN). It addresses nursing phenomena, actions, and outcomes. It contains descriptions and comparisons of nursing practices locally, regionally, nationally, and internationally. It articulates the contributions of nursing to health and health care, enhances communications, and improves the quality and continuity of health care on a global basis.