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A&E Test 2 > Health Informatics and Documentation > Flashcards

Health Informatics and Documentation Flashcards

1
Q

How common are medical errors?

A

-Really common, more people die from medical errors then motor accidents

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2
Q

Health Informatics

A

Uses technology and information to

  1. coordinate PT care
  2. manage knowledge
  3. reduce error
  4. support decision making
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3
Q

2007 the Nursing Informatics Working Group of the American Informatics Medical Association did what?

A

-published a white paper that detailed the guideposts for informatics related to education, research and clinical practice

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4
Q

Nursing Informatics

A

-uses nursing science, computer science, information science to manage and communicate data, information, knowledge and wisdom within the nursing practice

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5
Q

what areas does nursing informatics affect:

A
  1. learning environments
  2. 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
  3. interprofessional collaboration
  4. patient care settings
  5. strategic planning
  6. patient satisfaction
  7. patient outcomes
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6
Q

Where can we use Nursing Informatics?

A
  • track patient outcomes
  • find data trends
  • assess workloads
  • assess interventions
  • develop technologies
  • improve workflows
  • help patients to cope with disease and diagnoses
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7
Q

Data-Information-Knowledge-Wisdom Pathway

A

the process of converting raw data into wisdom

used in all levels of nursing

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8
Q

What is data

A
  • 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
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9
Q

What is Information

A
  • 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’.
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10
Q

what is knowledge

A
  • 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
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11
Q

what is wisdom

A

-appropriate use of knowledge to manage and solve human problems, implies ethics, knowing why and why not, clinical judgement

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12
Q

what are some things information to be valuable

A

-accessible
-accurate
-timely
-complete
-cost effective
-flexible
-simple
-verifiable
-reliable
relevant
secure

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13
Q

applying the DIKW framework

A
  • 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
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14
Q

example of a piece of data

A

bp reading of 150/90

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15
Q

example of information

A

knowing the patient’s baseline BP and knowing that the patient has had HBP for 10 years

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16
Q

Example of knowledge

A

PT has history of CVD and is now appearing with angina and a sudden drop in BP so might be having a MI

17
Q

Example of Wisdom

A

-MONA! for MI

18
Q

there are new key skills the nurse must have

A
  • 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
19
Q

EHR integration 2009

A
  • 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
20
Q

what is predicted to happen in the future?

A
  • 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
21
Q

electronic medical record

A

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

22
Q

Electronic health record

A

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.

23
Q

personal health record

A

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.

24
Q

what kind of information do nurses add to the EHR

A
  • physical assessment
  • admission nursing note
  • nursing care plan
  • present complaint - symptoms
  • past medical history
  • tests/procedures/treatment
  • discharge
  • medication administration
  • daily documentation
25
Q

Integrated EHR could provide us with what sort of features?

A
  • alerts about abnormal test results, or other findings that need to come to the attention of the health care worker- but this is a double edged sword when someone has too many alters many providers just do not read them anymore and simply ignore them.
  • can be accessed by different people at one time and used from different locations
  • efficient use of storage space for PT information
  • data begins to come together
  • clinical support tools such as linkage to protocols related to PT issues pop up and are there to be seen and used
26
Q

‘bottom line’ of EHR why do we want them overall

A

-PT info is up to date and in real time, which helps different people from different places give and plan for the PT much better
timely, easily assessable

27
Q

what are barriers of EHR

A
  • implementation costs and funding
  • training is hard for so many people
  • organizational culture
  • lack of planning
  • not wanting to loose the PT RN connection like losing the ability to have conversations and have eye contact
  • not being able to type quickly
  • decreased critical thinking because everything is i boxes for you to click
28
Q

communication errors occur in shift change

A
  • 72% of patient errors were related to communication failures
  • they often happen at handoff time during a shift change
  • transfer of a patient from one unit to the other within the same institution or between different ones
29
Q

what is the best hand off report type

A

-walking rounds with the nurse form the last shift

30
Q

lowest form of hand off

A

-tape recording from the previous

31
Q

when do you you ISBARR vs SBAR

A

I AM CONFUSED WHETHER WE DO THESE ONLY WHEN YOU COMMUNICATE WITH A DOCTOR OR DURING HANDOFF ASWELL

32
Q

Interdisciplinary rounds

A
  • really good way for all disciplines to communicate

- each discipline plays a role in the management of PT and walk door to door

33
Q

what are some different types if nursing documentation

A
  • SOAP- Subjective, objective, assessment, plan
  • SOAPIE- subjective, objective, assessment, plan, intervention, evaluation
  • DAR- data, action, response
  • ADPIE- assessment, diagnosis, plan, intervention, evaluation
  • ADIE- assessment, diagnosis, intervention, evaluation
  • FOCUS NOTE
  • NARRATIVE NOTE
34
Q

what should you not do when documenting

A
  • alter PT record
  • chart ahead of time
  • include opinion not facts
  • write incorrect things
  • use abbreviations that aren’t acceptable
35
Q

what should we do when documenting

A
  • correct chart
  • reflect nursing process
  • write legibly
  • late entry
  • watch grammer, spelling, punctional
  • conversation with MD
  • tell whole story but do not add things

A&E Test 2 (2 decks)

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