EXAM 1 COMMUNICATION AND GROUP DYNAMICS NOW EXAM 4

Explain long-term health care documentation

- clinical documentation that improves care for residents and increases reimbursement for that care -department of health in states governs the frequency of written nursing records -interdisciplinary

clinical information systems -order entry systems

1. biometrics, supplies, services 2. orders/reminders-clinical physican order entry (CPOE) 3. clinical decision support systems (CDSS)

what are the different types of reports?

1. change of shift 2. telephone reports 3. verbal or telephone orders 4. transfer reports 5. incident reports

What are the 3 stages of HITECH?

Stage 1: focused on the capture of patient data and the ability of providers to share that data with patients and other health care professionals (2011-2012) Stage 2: focused on the exchange of health information among providers and the promotion of patient engagement through secure online access to personal health information (2014) Stage 3: includes recommendations for the expansion of the meaningful use objective to improve health care outcomes (2016)

The nurse is preparing written information regarding healthy lifestyle choices to be distributed to a group. To best assure the information will be understood, which must the nurse do first? a. determine how the informational sheets will be distributed b. assess the interest level the group has about the information c. identify when to distribute the informational sheets 4. effectively encode the message

b

A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record: a. an interpretation of patient behavior b. objective data that are observed c. lengthy entry using lay terminology d. abbreviations familiar to the nurse

b.

The nurse is discussing the impact of pesticides on the foods with a group. The nurse is most confident that the group understands the ways of minimizing the negative effects of pesticides when: a. the nurse overhears them talking about how much they liked the class, "that they talked about safe food" b. the class places a poster in the cafeteria that states, "wash your fruit before you eat it" c. during the discussion a member asked here to buy pesticide-free foods d. the group asks for another class on how to grow healthy food

b.

Which is true regarding nonverbal communication? a. it is more often misinterpreted than verbal communication b. it is often more important than verbal communication c. it relays very little of the senders true emotions and attitudes d. it basically focuses on transferring ideas and information to the receiver

b.

dynamic process involving the interchange of information, feelings, needs, and values that supports the quality of relationships

communication

home care documentation is done how?

computerized; document all services for payment

team members communicating in a group

conferences

a professional caregiver providing formal advice to another caregiver

consultations

interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame

critical pathways

A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to: a. exchange information among health care members b. provide information about patients from one unit to another unit c. ensure proper care for the patient d. aid in the hospital's quality improvement program

d.

record: includes medications, diet, community resources, follow-up care, who to contact in case of emergency or questions

discharge summary form

record: help team members quickly see patient trends overtime and decrease time spent on writing narratives

flow sheets and graphic records

Tuckman's: team acquaints and establishes ground rules. Formalities are preserved and members are treated as strangers

forming

Activities and responses of member of a group (any formal or informal gathering of three or more individuals) that include defined roles within a group, stages of group development/formation, and patterns of communication (both verbal and nonverbal) among the group members

group dynamics

TJC specifies what?

guidelines

Transitional care - reporting use what?

hand-off report

allows nurses to perform needed assessments, evaluate patients' progress, and determine the best interventions for patients' needs

hand-off report

steps of the nursing process are ____

measurable

Tuckman's: people feel part of the team and realize that they can achieve work if they accept other viewpoints

norming

Tuckman's: the team works in an open and trusting atmosphere where flexibility is the key and hierarchy is of little importance

performing

a system of organizing documentation to place the primary focus on patients' individual problems

problem-oriented medical record

key to successful implementation in the nursing process flow

process re-engineering key

encompasses the written communication within a professional context

professional communication

Data are __

raw facts

record: preprinted, established guidelines used to care for patients who have similar health problems (electronic)

standardized care plans

collection tool for information manaagment

standardized document

Tuckman's: members start to communicate their feelings but still view themselves as individuals rather than part of the team. They resist control by group leaders and show hostility

storming

Experts believe that implementing EHRs across the health care delivery system will do what?

will decrease costs and improve the quality of patient care Certified EHR technology

Elements of professional communication

1. appearance, demeanor and behavior 2. use of names 3. autonomy and responsibility 4. courtesy 5. trustworthiness 6. assertiveness

advantages of nurse informatics

1. bilingual 2. support nursing work processes using technology 3. re-engineer clinical workflow and facilitate change management

Social determinants of health include?

1. biology/genetics 2. individual behavior 3. social environment 4. physical environment

formats of progress notes and what they include?

1. SOAP (subjective data, objective data, assessment, plan) 2. SOAPIE (R) (subjective data, objective data, assessment, plan, intervention, evaluation) (revision to plan) 3. PIE (identifies a nursing diagnosis- problem, interventions that will be used, evaluation) 4. SBAR (situation, background, assessment, recommendations) 5. Focus Charting DAR (data, action on nursing intervention, response of the patient)

How does nursing informatics attribute to the nursing specialty?

1. a differentiated practice 2. a defined research program 3. an organizational representation 4 .education programs 5. credentialing mechanism

What are some common record forms?

1. admission nursing form 2. client care summary or Kardex 3. standardized care plans 4. flow sheets and graphic records 5. acuity records 6. discharge summary form

Types of data?

1. alpha 2. numeric 3. audio 4. image 5. video

How does informatics add value?

1. analyze clinical and financial data 2. promote and facilitate access to resources and references 3. provide nursing content to standardized languages 4. improve relationships between providers and recipients of health care 5. cost savings - prevention primary care

Purposes of a health record

1. communication - what was patient's condition? Was it easy to find? 2. legal record- what is point of charting? best legal defense 3. financial billing- basis for reimbursement. What is a DRG? What is a case mix? 4. auditing, monitoring 5. Research- determines changes made to nursing procedures and protocols; to improve quality of care 6. education- important part of nursing practice; nursing skill

key advantages of EHR

1. compare current clinical data about a patient with data from previous health care encounters 2. maintain an ongoing record of health education provided patient's response to that information

Communication involves?

1. critical thinking 2. perseverance and creativity 3. self-confidence 4. humility 5. integrity

Major sections of POMR

1. database 2. problem list 3. care plan 4. progress notes 5. charting by exception

Who are informatics nurses?

1. expert nursing clinicians in utilizing the nursing process 2. clinicians with extensive clinical practice 3. have additional education and experience related to technology and information systems

ANA standards for documentation include:

1. factual 2. current 3. organized 4. complete 5. accurate

Tuckman's stages of group formation includes

1. forming 2. storming 3. norming 4. performing 5. adjourning

skills of a group include

1. group building 2. performing in a group 3. group maintenance

NI- categories of competencies?

1. information literacy and management 2. computer skills and competencies 3. informatics knowledge and skills

What are the different methods used for record keeping?

1. narrative documentation 2. problem-oriented medical record

informatics is a combination of what 3 things?

1. nursing science 2. information science 3. computer science

ways of recording

1. paper-record 2. electronic health record (EHR) 3. medical record 4. narrative 5. problem-oriented medical record (POMR)

The Omaha System consists of what 3 components?

1. problem classification scheme 2. intervention scheme 3. problem rating scale for outcomes

Multidisciplinary communication includes?

1. records or charts 2. reports 3. consultations 4. referrals 5. conferences

Case management involves?

1. screening 2. assessment 3. planning 4. implementation 5. monitoring/review 6. exit planning

Case Management conducts assessments to determine what?

1. service needs 2. service referral 3. monitoring and service provision

What are techniques/ways of reporting?

1. source records 2. charting by exception 3. case management model

roles in a group

1. spokesperson 2. captain 3. recorder 4. reflector 5. conflict resolver

Nursing Process Flow?

1. standardized document 2. information management 3. process re-engineering 4. research and evidence collection

What is the reporting process?

1. telephone reports and orders -SBAR 2. document every call 3. read back

Narrative documentation: 1. ____ used 2. big where? 3. what type of format?

1. traditionally 2. community health 3. story-like

well-documented information provides?

1. what care has been provided 2. outcomes/responses to plan of care 3. current patient status and assessments 4. support decisions based on assessments to drive new plans of care

defines "what" and "how" of practice

Cornerstone of Professional Nursing Practice

disadvantage of critical pathways advantages

D- different for every person A- allowing multiple people in a health care team; all disciplines to be able to help with an intervention; triggers a thinking process

a digital version of patient data: longitudinal (lifetime) Record

EHR

What is the difference between a medical record and an electronic health record?

EHR- your own health record that you have access to Medical record- owned by hospital

the legal record that describes a single encounter/visit (source of data for the EHR)

EMR

HITECH established provisions to promote the meaningful use of what to improve the quality and value of heatlh care? who has not used this yet?

HIT health information technology; nurses

health information technology industry was area when lawmakers saw opportunity to stimulate the economy and improve health care delivery; certified EHR technology/meaningful use (quality use); enhanced HIPAA security

Health Information Technology for Economic and Clinical Health Act of 2011 (HITECH)

Documentation needs to conform with what standards to maintain institutional accreditation/minimize liability

NCQA and TJC

used to document the clinical assessment and care provided; Medicare and Medicaid Services mandates the use of this for collecting and reporting patient assessments and outcomes in the home care setting; includes a comprehensive admission assessment and calculates clinical, functional, and service scores to provide justification for reimbursement of services

OASIS

theory about enhancing the quality of life includes the work environment; continuous mutual interaction with environment

Parse's Theory of Human Becoming

require quality improvement programs and set standards for the information needed in patient records, including evidence of an individualized plan of care developed with a patient's input, discharge planning, and patient education

TJC

Act that includes Medicare and Medicaid legislation for long-term care documentation

The Omnibus Budget Reconciliation Act of 1987

focuses on better preparing the clinical workforce to use technology and informatics to improve the delivery of patient care

The Technology Informatics Guiding Education Reform (TIGER) --> NOW Healthcare Information and Management Systems Society (HIMSS)

Information regarding a patient's health status may not be released to non-health care team members because: a. legal and ethical obligations require health care providers to keep information strictly confidential b. regulations require health care institutions to document evidence of physical and emotional well-being c. reimbursement issues related to patient care and procedures may be of concern d. fragmentation of nursing and medical care procedures may be identified

a.

record: used for determining the hours of care/staff required for a given group of patients; not part of a patient's medical record

acuity records

Meaningful use of informatics? (EHR)

addressing computer systems that backup the use of EHR -- everyone has EHR by 2018 (hasn't happened but close)

Tuckman's: the team conducts on assessment of the year and implements a plan for transitioning roles and recognizing members' contributions

adjourning

Record: guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems

admission nursing history form

includes medical record numbers, patient names

alpha, numeric

What type of data does nursing informatics gather?

analtytical--> turn it into knowledge

model that incorporates an interprofessional approach to documenting patient care

case management

technique; way of reporting: incorporates a multidisciplinary approach to documenting patient care; includes: patient problems, key interventions, expected outcomes within timeframe; variances noted/charted

case management model

technique/way of reporting: reduces documentation time; highlights trends/changes; focuses on documenting deviations

charting by exception

record: patient care summary: portable "flip over" file on notebook with patient info

client care summary or Kardex

reports that are used when something is inconsistent with care of unity, quality improvement issue, not part of a client's record, documentation of error in litigious society

incident reports

the discipline concerned with the study of information and manipulation of information via computer-based tools

informatics

key role for Nursing Informatics/key to research and evidence collection

information management

A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice

nursing informatics

a research-based, comprehensive practice and documentation standardized taxonomy designed to describe client care; a comprehensive evaluation of nursing care/evaluates quality of nursing care in home care setting

omaha system

confidential permanent legal document; contains accurate account of client's health status

records or chart

arrangement for services by another care provider

referrals

oral, written, audio-taped exchange of information; include change of shift, telephone, transfer and incident reports

reports

key to repeatable, standardized care and improved outcomes

research and evidence collection

Why is documentation significant?

show what we do and what we're worth

sort a categorize data for purpose of addressing relationships

social determinants of health

technique/way of reporting: a separate section for each discipline, disjointed

source records

a continuous and dynamic process whereby two or more individuals send, receive, and validate information exchanged among them. The information can be verbal, nonverbal, non-linguistic, face-to-face, written or virtual

therapeutic communication

In the 1980s what did we do?

tried to change to informatics -- nursing engineers -- to change behavior and culture