Informatics/Documentation

Common Record-Keeping Forms

-Admission nursing history form Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems -Flow sheets and graphic records Help team members quickly see patient trends over time and decrease time spent on writing narrative notes -patient care summary -standardized care plans or clinical care guidelines Preprinted, established guidelines used to care for patients who have similar health problems -discharge summary forms

technology

the knowledge and use of tools, machines, materials, and processes to help solve human problems.

informatics

the science that encompasses information science and computer science to study the process, management, and retrieval of information.

Regional health information organization

Oversees communication and exchange of information in a geographic area

electronic medical record

Person's health record within a provider's health care facility

Standardization

Standardization for information systems and terminology has been critical for communicating care. Standardization also links to: Efficiency Cost containment Codified terminology Taxonomies and nomenclature

Documentation in the Home Healthcare Setting

-Documentation in the home care system is different from that in other areas of nursing. -Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third-party payers. Nurses must document all of their services for payment. -Nurses use two different data sets to document the clinical assessments and care provided in the home care setting: the Outcome and Assessment Information Set (OASIS) and the Omaha System. -The Centers for Medicare and Medicaid Services (CMS) mandates the use of OASIS for collecting and reporting patient assessments and outcomes in the home care setting. -The Omaha System consists of three components: Problem Classification Scheme, Intervention Scheme, and Problem Rating Scale for Outcomes. It provides a useful model for the comprehensive evaluation of nursing care and evaluates the quality of nursing care provided in the home care setting

Documentation in the Long-Term Healthcare Setting

-Governmental agencies are instrumental in determining standards and policies for documentation. -Documentation in the long-term care setting supports an interprofessional approach to the assessment and planning process for all patients.

Documentation

-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. -constitutes a fundamental tenet of nursing care. It must be accurate and comprehensive. -the information communicated by nurses regarding their patients' care reflects the quality of care and accountability for care provided. -effective documentation helps ensure continuity of care, saves time, and minimizes the risk of errors. -the quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the health care system, and legal guidelines make documentation and reporting an extremely important nursing responsibility.

Electronic health record

Central component of the health IT infrastructure

Methods of Reporting

Charting by exception (CBE)- Focuses on documenting deviations Case management plan and critical pathways- Incorporate a multidisciplinary approach to care Variances The philosophy behind charting by exception (CBE) is that a patient meets all standards unless otherwise documented. The predefined statements used to document nursing assessment of body systems are called within defined limits (WDL) or within normal limits (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. You only write a progress note when a patient's assessment does not meet the standardized criteria for "normal" in one or more body systems. When changes in a patient's condition develop, you need to include a thorough and precise description of the effects of the change(s) on the patient and the actions taken to address the change(s) in the progress note. The case management model of delivering care (see Chapter 2) incorporates an interprofessional approach to documenting patient care. Critical pathways (also known as clinical pathways, practice guidelines, critical pathways, or CareMap® tools) are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame. Many organizations summarize the standardized plan of care into critical pathways for a specific disease or condition. Evidence-based critical pathways improve patient outcomes. 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 variances. A variance occurs when the activities on the critical pathway are not completed as predicted or a patient does not meet the expected outcomes. A positive variance occurs when a patient progresses more rapidly than expected. Once you identify a variance, you modify the patient's care to meet the needs associated with the variance. Over time health care teams revise critical pathways when similar variances recur.

Health Informatics: Three Major Domains

Clinical informatics Translational bioinformatics Public health informatics

Purposes of the Medical Record

Communication Reimbursement Research Legal documentation Education Auditing/monitoring

Exemplars

Computerized Nursing Documentation Bar Code Medication Administration Clinical Decision Support Systems Electronic Health Record

Guidelines of Quality Documentation

Factual Accurate Complete Current Organized Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized. It is easier to maintain these characteristics if you continually seek to express ideas clearly and succinctly by: Sticking to the facts. Writing in short sentences. Using simple, short words. Avoiding the use of jargon or abbreviations. A factual record contains descriptive, objective information about what a nurse observes, hears, palpates, and smells. Avoid vague terms such as appears, seems, or apparently. The only subjective data that you include in the record is what a patient says. The use of exact measurements establishes accuracy and helps you determine if a patient's condition has changed in a positive or negative way. It is essential to avoid the use of unnecessary words and irrelevant detail. Consult the TJC's "do not use" list of abbreviations. Correct spelling demonstrates a level of competency and attention to detail. You need to date and time all entries in medical records, and there needs to be a method to identify the authors of all entries. You need to ensure that the information within a recorded entry or a report is complete, containing appropriate and essential information. Follow established criteria and standards for thorough communication within the medical record or when reporting certain health problems or nursing activities. Timely entries are essential in a patient's ongoing care. Delays in documentation lead to unsafe patient care. Most health care agencies use military time. Document the following activities or findings at the time of occurrence: Vital signs Pain assessment Administration of medications and treatments Preparation for diagnostic tests or surgery, including preoperative checklist Change in patient status and who was notified (e.g., physician, manager, patient's family) Admission, transfer, discharge, or death of a patient Treatment for sudden change in patient status Patient's response to treatment or intervention Information entered into a medical record facilitates communication when it is documented in a logical order.

personal health record

Individual's self-maintained health record. Sent by a physician.

Nursing Clinical Information Systems

The nursing process design is the most traditional. It organizes documentation within well-established formats such as admission and postoperative assessment problem lists, care plans, intervention lists or notes, and discharge planning instructions. The nursing process design facilitates the following: Generation of a nursing work list that outlines routine scheduled activities related to the care of each patient. Documentation of routine aspects of patient care such as hygiene, positioning, fluid intake and output, wound care measures, and blood glucose measurements. Progress note entries using narrative notes, charting by exception, and/or flow sheets. Documentation of medication administration. The protocol or critical pathway design facilitates interdisciplinary management of information because all health care providers use evidenced-based protocols or critical pathways to document the care they provide. The information system allows a user to select one or more appropriate protocols for a patient. Standard health care provider order sets are included in the protocols and automatically processed. Integrates appropriate information into the medication delivery process to enhance patient safety. Identifies variances of the anticipated outcomes on the protocols as documentation is entered. Some specific advantages include: 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 (e.g., TJC). Development of a common clinical database. Enhanced ability to track records. Many nursing clinical information systems (NCISs) include content-importing technologies that allow the use of templates, macros, automated data points, and the ability to copy forward either parts of or entire nursing shift assessments that enable nurses to quickly document their assessment or the care they provided

Clinical informatics

When used in health care delivery, is essentially the same regardless of the health professional group involved, i.e.-nurses, doctors, etc. Nursing informatics (combines nursing science and a multitude of knowledge to provide patient care) Consumer informatics (Helps the potential patient to make health care decisions.)

health informatics

a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology.

consumer health informatics

a subset of clinical health care informatics. It is a form of health information technology that is geared toward better health care decision making based on the consumer's perspective. It includes technologies focused on patients as the primary users of health information.

nursing informatics

a subset of clinical health care informatics. The American Nurses Association defines nursing informatics as "a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. NI [Nursing informatics] supports consumers, patients, nurses, and other providers in their decision-making in all roles and settings. The support is accomplished through the use of information structures, information processes, and information technology."