Information Management in Healthcare - Documenting and Reporting

Question 1

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

Answer 1

Information technology (IT)

Question 2

The intersection of clinical, IM/IT [Information Management/Information Technology] and management practices to achieve better health.

Answer 2

Health informatics

Question 3

A group of systems used within a health care organization to support and enhance health care.

Answer 3

Health care information system (HIS)

Question 4

Consists of two major types of information systems: clinical information systems and administrative information systems. Together the two systems operate to make the entry and communication of data and information more efficient. Any single health care agency uses one or several of these systems.

Answer 4

Health care information system (HIS)

Question 5

Nursing competence in healthcare i___ is becoming a priority as healthcare providers and facilities across Canada implement electronic documentation.

Answer 5

i-nformatics

Question 6

Nurses need i___ competencies to deliver safer and more efficient care, to add to the nursing professional knowledge base, and to facilitate the growth of evidence-informed practice.

Answer 6

i-nformatics

Question 7

Professional organizations recommend that all nurses acquire a minimal level of awareness and competence in informatics and use of ___ ___ (IT).

Answer 7

information technology

Question 8

The ability to communicate using information technologies to support engagement with patients/clients and the interprofessional team is an es___ component of baccalaureate nursing education.

Answer 8

es-sential

Question 9

The Nursing Informatics Entry-to-Practice Competencies for Registered Nurses outlines three entry-to-practice competencies related to nursing informatics: (1) use of relevant information and knowledge to s___ the delivery of evidence-informed patient care; (2) use of information and communication technologies (ICTs) in accordance with professional and regulatory s___ and workplace p___; and (3) use of i___ and c___ t___ in the delivery of patient/client care. These nursing informatics competencies are considered the mi___ knowledge and skills that new graduate nurses require in order to practise.

Answer 9

s-upport

s-tandards / p-olicies

i-nformation / c-ommunication / t-echnologies

minimum

Question 10

Competence in informatics is not the same as computer competency. To become competent in informatics, nurses need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that, as a nurse, you learn to recognize when information is needed and have the skills to f___, e___, and u___ that information effectively. You also need to know how to use clinical databases within your institution and apply the information so you can deliver high-quality, appropriate patient care.

Answer 10

f-ind

e-valuate

u-se

Question 11

All members of the interprofessional health care team, including nurses, physicians, pharmacists, social workers, and therapists, use programs available on a c___ information system (CIS). These programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems.

Answer 11

c-linical

Question 12

A mo___ system includes devices that automatically monitor and record biometric measurements (e.g., vital signs, oxygen saturation, cardiac index, and stroke volume) in acute care, critical care, and specialty areas. The devices electronically send measurements directly to the nursing d___ system.

Answer 12

mo-nitoring / d-ocutmentation

Question 13

Allows nurses to order supplies and services from another department. An example is a computer program that provides the ability to order sterile supplies from the central supply department. This eliminates the use of written order forms and expedites the delivery of needed supplies to a nursing unit.

Answer 13

Order-entry systems

Question 14

Allow health care providers to directly enter orders for patient care into the hospital information system. In advanced systems, CPOE has built-in reminders and alerts that help a health care provider select the most appropriate medication or diagnostic test. The direct entry of orders eliminates issues related to illegible handwriting and transcription errors. In addition, a CPOE system potentially speeds the implementation of ordered diagnostic tests and treatments, which improves staff productivity and saves money because the unit secretary no longer transcribes a written order onto a nursing order form. Orders made through CPOE are integrated within the record and sent to the appropriate departments (e.g., pharmacy or radiology).

Answer 14

Computerized provider order entry (CPOE) systems

Question 15

Computerized programs used within the healthcare setting to aid and support clinical decision-making. When used to support nursing decisions it is called a nursing CDSS.

Answer 15

Clinical decision support systems (CDSS)

Question 16

The knowledge base within a CDSS 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. For example, an effective CDSS notifies healthcare providers of patient allergies before ordering a medication, which enhances patient safety during the medication ordering process. CDSSs also improve nursing care. When patient assessment data are combined with patient care guidelines, nurses are better able to implement evidence-informed nursing care, resulting in improved patient outcomes.

Answer 16

Clinical decision support systems (CDSS)

Question 17

Provides automatic decision support at the time and place nurses need it enhance the quality and safety of patient care. CDSSs also help nurses initiate evidence-informed care faster and with more accuracy, improving patient outcomes.

Answer 17

Clinical decision support systems (CDSS)

Question 18

Enhances the implementation of evidence-informed practise into nursing care because they remind nurses which interventions need to be implemented for specific patients at the time the care is needed.

Answer 18

Clinical decision support systems (CDSS)

Question 19

Nurses need to evaluate patient o___ when CDSSs are used.

Answer 19

o-utcomes

Question 20

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.

Answer 20

Nursing clinical information system (NCIS)

Question 21

Have two designs: 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.

Answer 21

Nursing clinical information system (NCIS)

Question 22

The nursing ___ 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

Answer 22

process

Question 23

More advanced systems incorporate standardized nursing languages such as the North American Nursing Diagnosis Association-International (NANDA-I) nursing diagnoses, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) into the software.

Answer 23

Nursing Clinical Information System (NCIS)

Question 24

The other model for an NCIS is the protocol or critical p___ design. This design facilitates interdisciplinary management of information because all healthcare providers use evidence-informed protocols or critical p___ to document the care they provide. The information system allows a user to select one or more appropriate protocols for a patient. An advanced system merges multiple protocols, using a master protocol or p___ to direct patient care activities. Standard healthcare provider order sets are included in the protocols and automatically processed. The system integrates appropriate information into the medication delivery process to enhance patient s___. In addition, the system identifies var___ of the anticipated outcomes on the protocols as documentation is entered. This provides all caregivers the ability to analyze var___ and offer an accurate clinical picture of a patient’s progress.

Answer 24

p-athway / p-athways / p-ath / s-afety / var-iences x2

Question 25

This system allows the following:

• 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

Answer 25

Nursing Clinical Information System (NCIS)

Question 26

Many 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.

Answer 26

Nursing Clinical Information System (NCIS)

Question 27

Many 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. These features have benefits and risks associated with their use. When allergy and current medication lists are automatically imported into nursing admission documentation from a previous hospital encounter, the nurse needs to meticulously re___ this information for accuracy and up___ it as needed to avoid documentation errors and patient safety concerns. When nursing shift assessment data are copied forward from a previous shift or day, the data must be up___ so they accurately reflect a patient’s c___ clinical status.

Answer 27

re-view / up-date / up-dated / c-urrent