Fundamentals Chapter 26

The use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research - is also recognized as a specialty area of nursing practice

Nursing Informatics

is broadly defined as the "use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research,"

Nursing Informatics

Nurses use acuity ratings to determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours. Based on type and number of nursing interventions required by a patient over a 24-hour period. The acuity level is a classification used to compare one or more patients to another group of patients.

Acuity Rating System

Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems

Admission nursing history form

ncorporates the principles of nursing informatics to support the work that nurses do by facilitating documentation of nursing process activities and offering resources for managing nursing care delivery.

nursing clinical information system

incorporates the principles of nursing informatics to support the work that nurses do by facilitating documentation of nursing process activities and offering resources for managing nursing care delivery. As a nurse you need to access a computer program easily, review a patient's medical history and health care provider orders, and then go to the patient's bedside to conduct a comprehensive assessment.

nursing clinical information system (NCIS)

Many computerized documentation systems have the ability to generate a ________ document that you review and sometimes print for each patient at the beginning and/or end of each shift. The document automatically updates and provides the most current information that has been entered into the EHR

patient care summary

communication, legal documentation, reimbursement, education, research and auditing and monitoring

what are the purposes of a medical record?

1. 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. legal and ethical obligations require health care providers to keep information strictly confidential.

• Better access to information. • Enhanced quality of documentation through prompts. • Reduced errors of omission. • Reduced hospital costs. • Increased nurse job satisfaction. • Compliance with requirements of accrediting agencies . • Development of a common clinical database. • Enhanced ability to track records.

Advantages of a Nursing Clinical Information System.

Hospitals establish quality improvement programs for conducting objective, ongoing reviews of patient care and to keep nurses informed of standards of nursing practice to maintain excellence in nursing care.

Auditing and monitoring

is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health record

Documentation

Nurses are legally and ethically obligated to keep all patient information confidential. Nurses are responsible for protecting records from all unauthorized readers. HIPAA requires that disclosure or requests regarding health information be limited to the minimum necessary.

Confidentiatility (For Nurses)

The _________ model of delivering care incorporates an interprofessional approach to documenting patient care.

Case managment

are computerized programs used within the health care setting to aid and support clinical decision making. When used to support nursing decisions it is called a nursing _____ The knowledge base within a _____ contains rules and logic statements that link information required for clinical decisions to generate tailored recommendations for individual patients, which are presented to nurses as alerts, warnings, or other information for consideration

Clinical decision support systems (CDSSs)

A patient's medical record is one way that members of the health care team communicate about patients' needs and responses to care, clinical decision making, individual therapies, content of consultations, patient education, and discharge planning.

Communication

are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame. The document facilitates the integration of care because all health care team members use the same critical pathway to monitor a patient's progress during each shift or, in the case of home care, every visit

Critical pathways

4. 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. aid in the hospital's quality improvement program.

Telephone calls made to a provider Document every call Telephone and verbal orders Telephone orders (Tos) Verbal orders (Vos) Incident or occurrence reports Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient Follow agency policy

Documenting Communication with Providers and Unique Events

Patient's lifetime of health record. Making a positive impact on the quality of patient care through inter professional collaboration with improved data availability and information synthesis, and improving patient safety through the use of clinical decision support.

EHR (ELECTRONIC HEALTH RECORD)

is the legal record that describes a single encounter or visit created in hospitals and outpatient health care settings that is the source of data for the EHR (

EMR (ELECTRONIC MEDICAL RECORD)

One way to learn the nature of an illness and an individual's response to it is to read a patient care record.

Education

Acute and critical care nurses commonly use _________ to document physiological data and routine care. Within a computerized documentation system these forms allow you to quickly and easily enter assessment data about a patient such as vital signs, admission and or daily weights, and percentage of meals eaten. They also facilitate the documentation of the provision of routine, repetitive care such as hygiene measures, ambulation, and safety and restraint checks. These documents provide current patient information accessible to all members of the health care team and help team members quickly see patient trends over time. You explain any occurrence on a flow sheet that is unusual or represents a significant change in a patient's condition in detail in a progress note. For example, if a patient's blood pressure becomes dangerously high, you first complete and record a focused assessment and then document the action taken in a progress note.

FLOW SHEETS & GRAPHIC RECORDS

Help team members quickly see patient trends over time and decrease time spent on writing narrative notes

Flow sheets and graphic records

Use clear, concise descriptions in the patient's own language. • Provide step-by-step instructions for how to perform any procedure that the patient or family will be doing independently (e.g., emptying a urinary catheter drainage bag or self-administration of an injectable medication). • Identify precautions to follow when performing self-care or administering medications. • List signs and symptoms of complications that a patient needs to report to a health care provider. • List names and phone numbers of health care providers and community resources that the patient can contact. • Identify any unresolved problems, including plans for follow-up and continuous treatment. • List actual time of discharge, mode of transportation, and who accompanied the patient.

Guidelines for Information to Include on a Discharge Summary

• Clearly determine the patient's name, room number, and diagnosis. • Use clarification questions to avoid misunderstandings. • Write TO (telephone order) or VO (verbal order), including date and time, name of patient, the complete order; sign the name of the physician or health care provider and nurse. • Read back any prescribed orders to the physician or health care provider. • Follow agency policies; some institutions require telephone (and verbal) orders to be reviewed and signed by two nurses.

Guidelines for Telephone and Verbal Orders

You must safeguard any information that is printed from the record or extracted for report purposes De-identify all patient data Special considerations for faxing

Handling and disposing of Information

An incident or occurrence is any event that is not consistent with the routine, expected care of a patient or the standard procedures in place on a health care unit.

Incident or occurence report

The Technology Informatics Guiding Education Reform (TIGER) is focused on better preparing the clinical workforce to use technology and informatics to improve the delivery of patient care TIGER transformed to Healthcare Information and Management Systems Society (HIMSS) Competence in informatics is not the same as computer competency.

Informatics and Information Management in Health Care

refers to the management and processing of information, generally with the assistance of computers.

Information Technology

Accurate documentation is one of the best defenses for legal claims associated with nursing care

Legal documentation

_________ is the method traditionally used to record patient assessment and nursing care provided. It is simply the use of a storylike format to document information. In an electronic nursing information system, this is accomplished through use of free text entry or menu selections - tends to be time consuming and repetitious. It requires the reader to sort through a lot of information to locate desired data. However, some nurses believe that in certain situations use of this method provides better detail of individual patient assessment findings and/or complex patient situations

Narrovite documentatiom

P: Anxiety related to perceived threat of postoperative pain as evidenced by statement of prior experience with uncontrolled postoperative pain. I: Explained importance of postoperative ambulation and demonstrated TCDB exercises. Described analgesic plan of care. Encouraged to inform nursing staff as soon as possible if pain is not relieved. Provided teaching booklet on postoperative nursing care. E: Stated, "I feel less anxious about postoperative pain now" and performed return demonstration of TCDB exercises correctly. Needs review of postoperative nursing care.

PIE

Problem-Intervention-Evaluation (PIE)

PIE

The _________ is a system of organizing documentation to place the primary focus on patients' individual problems. Data are organized by problem or diagnosis. Ideally each member of the health care team contributes to a single list of identified patient problems, which coordinates a common plan of care. The POMR has the following major sections: database, problem list, care plan, and progress notes.

PROBLEM-ORIENTATED MEDICAL RECORD (POMR)

what is a valuable source of data for all members of the health care team?

Patient Medical Record

Documentation by all members of the health care team is used to determine the severity of illness, the intensity of services received, and the quality of care provided during an episode of care

Reimbursement

After securing appropriate agency and institutional review board (IRB) approval, researchers use patient records to gather statistical data on the incidence and prevalence of health problems, complications, use and effectiveness of specific medical and nursing interventions, outcomes in recovery from illness, and deaths.

Research

SOAPIE

S-ubjective O-bjective A-ssessment P-lan I-ntervention E-valuation

S: "I'm worried about the surgery. Last time I had a lot of pain when I got out of bed." O: Asking multiple questions about how postoperative pain will be addressed. A: Anxiety related to perceived threat of postoperative pain as evidenced by statement of prior experience with uncontrolled postoperative pain. P: Explain routine postoperative analgesic plan of care. Encourage to inform nursing staff as soon as possible if pain is not relieved. Explain rationale for early postoperative ambulation and demonstrate TCDB exercises. Provide teaching booklet on postoperative nursing care.

SOAP

subjective, objective, assessment, plan

SOAP

to facilitate the creation and documentation of a nursing and or interprofessional plan of care. Each CPG facilitates safe and consistent care for an identified problem by describing or listing institutional standards and evidence-based guidelines that are easily accessed and included in a patient's EHR. After completing a nursing assessment, the nurse identifies the CPGs that are appropriate for the patient and selects each one to be included in an individualized plan of care within the EHR. Most computer documentation systems allow CPGs to be modified, allowing you to individualize interventions, goals, and/or outcomes for each patient. useful when conducting quality improvement audits. They also improve continuity of care among professional nurses. When they are used, the nurse remains responsible for providing individualized care to each patient. -cannot replace a nurse's professional judgment and decision making. Update care plans or CPGs on a regular basis to ensure that the documents are appropriate and evidence based.

Standardized Care plans or clinical practice guidelines (CPGs)

A critical pathway eliminates nurses' notes, flow sheets, and nursing care plans because the document integrates all relevant information. Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway are called _________. A _______ occurs when the activities on the critical pathway are not completed as predicted or a patient does not meet the expected outcomes. A positive ______ occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter is discontinued a day early). An example of a negative _______ is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. You document all _______ on the critical pathway. Analysis of _______ identifies trends and provides data to develop an effective action plan to respond to identified patient problems. _________ sometimes result from changes in a patient's health or because of other health complications not associated with the primary reason for which a patient requires care. Once you identify a _______ you modify the patient's care to meet the needs associated with the ________. Over time health care teams revise critical pathways when similar ________ recur.

Variance

an effective _______ notifies health care providers of patient allergies before ordering a medication, which enhances patient safety during the medication ordering process. -also improve nursing care. When patient assessment data are combined with patient care guidelines, nurses are better able to implement evidence-based nursing care, resulting in improved patient outcomes

an example of CDSS

2. 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-objective data that are observed

3. A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of: A. PIE documentation. B. SOAP documentation. C. narrative charting. D. charting by exception.

c-narrative charting

CBE

charting by exception focuses on documenting deviations is that a patient meets all standards unless otherwise documented.

are computerized programs used within the health care setting to aid and support clinical decision making.

clinical decision support system

Nurses help ensure cost-effective care and appropriate reimbursement by preparing patients for an effective, timely discharge from a health care institution. The development of a comprehensive plan for safe discharge relies on interprofessional discharge planning. This process includes identification of key clinical outcomes and appropriate timelines for reaching them, the appropriate level of care for discharge, and all necessary resources.

discharge summary forms

Basic demographic data (e.g., age, religion) • Health care provider's name • Primary medical diagnosis • Medical and surgical history • Current orders from health care provider (e.g., dressing changes, ambulation, glucose monitoring) • Nursing care plan • Nursing orders (e.g., education needed, symptom relief measures, counseling) • Scheduled tests and procedures • Safety precautions used in the patient's care • Factors that affect patient independence with activities of daily living • Nearest relative/guardian or person to contact in an emergency • Emergency code status (e.g., indication of "do not resuscitate" order) • Allergies

examples of patient care summary