Health Informatics and Documentation Flashcards
How common are medical errors?
-Really common, more people die from medical errors then motor accidents
Health Informatics
Uses technology and information to
- coordinate PT care
- manage knowledge
- reduce error
- support decision making
2007 the Nursing Informatics Working Group of the American Informatics Medical Association did what?
-published a white paper that detailed the guideposts for informatics related to education, research and clinical practice
Nursing Informatics
-uses nursing science, computer science, information science to manage and communicate data, information, knowledge and wisdom within the nursing practice
what areas does nursing informatics affect:
- learning environments
- meaningful use- something that was developed by Obama Care made at center for Medicare & Medicaid and its an electronic health record. Did not work really well so government began giving $ incentives for whoever joined the program
- interprofessional collaboration
- patient care settings
- strategic planning
- patient satisfaction
- patient outcomes
Where can we use Nursing Informatics?
- track patient outcomes
- find data trends
- assess workloads
- assess interventions
- develop technologies
- improve workflows
- help patients to cope with disease and diagnoses
Data-Information-Knowledge-Wisdom Pathway
the process of converting raw data into wisdom
used in all levels of nursing
What is data
- smallest component of the DIKW pathway
- discrete or raw facts
- products of observations with little interpretation, little factors describing a patient, a datum with little meaning by itself without other context
What is Information
- information= data + meaning
- processed to have meaning
- constructed by combing different data points into a meaningful picture, giving context, answering questions of ‘who’ ‘what’ ‘where’ and ‘when’.
what is knowledge
- information that has been synthesized so that relations and interactions are formalized, built meaningful information, affected by assumptions and theories, derived from discovering patterns relationship
what is wisdom
-appropriate use of knowledge to manage and solve human problems, implies ethics, knowing why and why not, clinical judgement
what are some things information to be valuable
-accessible
-accurate
-timely
-complete
-cost effective
-flexible
-simple
-verifiable
-reliable
relevant
secure
applying the DIKW framework
- collecting data to make meaningful information
- the synthesis of information and use of the information
- applying the knowledge as a tool in practice
- clinicians act according to the knowledge
- use of wisdom to interpret and make clinical judgements using the information received
example of a piece of data
bp reading of 150/90
example of information
knowing the patient’s baseline BP and knowing that the patient has had HBP for 10 years
Example of knowledge
PT has history of CVD and is now appearing with angina and a sudden drop in BP so might be having a MI
Example of Wisdom
-MONA! for MI
there are new key skills the nurse must have
- use and contribute to the electronic health record
- find and evaluate relevance of evidence to support clinical decisions
- use data to solve PT and system problems
EHR integration 2009
- Obama Administration created an incentive through the American Recovery and Investment Act of 2009 of $19 billion dollars for providers to integrate EHR into their systems
- now there are penatilies for people who do not have EHR
what is predicted to happen in the future?
- integration of EHR throughout the health system will accelerate significantly, particularly with the financial incentives the government has implemented
- nurses need to be able to use these records
electronic medical record
electronic record of health related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within ONE health care organization EMR info can be part of the EHR
Electronic health record
an electronic record of health related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed and consulted by authorized clinicians and staff across more than one health acre organization.
personal health record
electronic record of health related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed shared and controlled by the individual.
what kind of information do nurses add to the EHR
- physical assessment
- admission nursing note
- nursing care plan
- present complaint - symptoms
- past medical history
- tests/procedures/treatment
- discharge
- medication administration
- daily documentation
