ch 26 informatics Flashcards
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
flow sheets and graphic records
history and
physical examination, nursing admission history and ongoing assessment, physical therapy assessment, laboratory reports, and
radiologic test results
database section
basic demographic data, health care provider’s name, primary medical diagnosis, and current orders.
summary
Health care team members monitor
and record the progress made
toward resolving a patient’s problems in progress notes
occurs when the activities on the critical pathway are not completed as predicted or the patient does not meet expected
outcomes
variance
is when a patient develops pulmonary complications after surgery, requiring oxygen
therapy and monitoring with pulse oximetry
negative variance
occurs when a patient progresses more rapidly than expected (e.g.,
use of a Foley catheter may be discontinued a day early
positive variance
includes medications, diet, community resources, follow-up care, and who to contact in case of an
emergency or for questions.
Discharge documentation
include standardized care plans or clinical practice guidelines (CPGs) to facilitate the
creation and documentation of a nursing and or interprofessional plan of care
computerized documentation systems
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. An interprofessional plan of care is used rather than a nursing process form
home health care
Outcome and Assessment Information Set (OASIS), and the Omaha System
Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA), is the data set that is federally mandated for use in long-term care facilities by CMS.
mds is reimbursment
skilled nursing facilities (SNFs)/ long-term care facilities (same)
is the protocol or critical pathway design. This design
facilitates interdisciplinary management of information because all health care providers use evidence-based protocols or critical
pathways to document the care they provide
Nursing Clinical Information Systems (NCIS)
design is the most traditional
design for an NCIS. This design organizes documentation within well-established formats such as admission and postoperative assessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes
nursing process
allow health care providers to directly enter orders for patient care into the hospital’s information system.
computerized provider order
entry (CPOE) systems
