Nursing Informatics Flashcards
nursing informatics
a science and practice which integrates nursing, its information and knowledge, and their management, with information and communication technologies to promote the health of people, families, and communities worldwide
information and communication technologies
encompasses all digital and analogue technologies that facilitate the capturing, processing, storage, and exchange of information via electronic communication
CARNA entry to practice competencies
o As professional = demonstrates professional judgement to ensure social media and information and communication technologies (ICTs) are used in a way that maintains public trust in the profession
o As communicator = uses ICTs to support communication
o As educator = assists clients to access, review, and evaluate information they retrieve using ICTs
o As scholar = engages in activities to strengthen competence in nursing informatics, identifies and analyzes emerging evidence and technologies that may change, enhance, or support health care
informatics, digital technology, information and communication technologies will enter into many aspects of care
o Health technology that generates (records and sends) data
o Documentation
o Transfer of patients between points of care
o Health education
o Evidence based care
electronic medical records
• Same idea as a patient’s hardcopy medical chart
• Used within one health care facility
• Include documentation, medical history, medications, and diagnostic and imaging reports related to one facility or team
• Benefits:
o Easy and quick documentation and access to patient information
o Improved monitoring by trending and tracking health information
o Access to clinical guidelines and tools
o Tool for health teaching
o Research opportunities: quality improvement and care planning
electronic health records
allow data entry and viewing across multiple services and across a lifetime
electronic health records allow and provide
- An electronic record that provides each individual in Canada with a secure and private lifetime record of their key health history and care within the health system
- These records allow nurses, pharmacists, therapists, doctors, and other members of the health care team to view and update a patient’s health record
- Currently, Canadian stakeholders are working towards implementing electronic health records for each province and territory
- Point-of-care system for data entry and retrieval
- Interoperability
functionality of electronic health records
- Client registry (eg. personal information)
- Provider registry (eg. home care nurse)
- Diagnostic imaging (eg. x-ray)
- Drug information system (eg. current meds)
- Laboratory information system (eg. blood work)
- Medication profiles
- Clinical reports (eg. discharge summary)
advantages of electronic health records
- Legibility
- Availability
- Ease of updating
- Storage
- Improved patient safety
challenges of electronic health records
- Upfront costs
- Collaboration of expertise
- Protecting privacy
nursing opportunities of electronic health records
work with other health professionals towards optimal, collaborative patient care and systematically document their interventions and the resulting outcomes
patient benefits of electronic health records
- Care during medical emergencies
- Monitoring and management of chronic diseases
- Wait times for diagnostic, screening or treatment procedures
- Use of diagnostic or screening results with reduced unnecessary repetition
- Diagnosis and treatment with information sharing
- Access for rural groups
consumer health solutions
enables the patient to enter, review and share personal health information
- Includes information added by the individual
- Less comprehensive than an HER, similar in scope to an EMR but includes different health information
- May be an isolated document, but ideally is integrated and overlaps with an EHR
assessment and teaching for personal health records
- Health literacy
- Health teaching = understanding the information contained, what information is important to document
- Basic teaching about how to access and use
benefits of personal health records
- Supporting self-management
- Improves communication between and patient and health care professionals
- Allows for personalized health teaching
optimizing care delivery using ICT
o Virtual and mobile healthcare o Documentation o Decision support at the point-of-care o Preventing gaps in patient care o Improving inter-professional care o Supporting the nurse-client relationship
virtual health
health professionals care from a different location than the patient
o Has the potential to replace in-person visits
o Manner of providing care in remote locations
o Cost saving and convenient
mobile health
the use of wireless tools to deliver and access virtual care and/or health information
o Nurses can use devices to communicate, share information and monitor health
o Patients receive convenient care and increase their role in managing health
o Eg. email for prescription renewal, health-related apps
telehealth
uses telecommunication devices to provide patient care, education and health administration to remote sites
o 3 main solutions = live conferencing, store-and-forward, telemonitoring
advantages of documentation in electronic health records
o Improved detail by having documentation templates prompt information to be added
o Improved accuracy of documenting by point-of-care access
o Decreased redundant charting due to auto-populating of fields with pre-entered data
o Ability to assess gaps in care
o Decreased nursing time
o Increased communication via real-time and legible documentation
decision support at the point-of-care
o Nurses are able to access a wealth of information at the point-of-care to support critical thinking and decision making
o In order to realize this advantage nurses should: become familiar with how to access and manipulate information, use critical thinking to plan care and act based on all the information available, advocate for the integration of relevant clinical practice
prevent gaps in care
o Due to interoperability, clinical findings and concerns can be recorded and viewed by all authorized health team members
o In order to improve continuity of care, nurses should: clearly document their clinical findings and concerns, consulting other health care professionals to address concerns
decreased missed/late assessments or interventions
o Alerts or reminders may be included in EHRs based on clinical guidelines, medication record, or monitoring devices (eg. cardiac monitor)
o In order to prevent missed or late actions, nurses should: include patient preferences, use alerts to support (not replace) critical thinking, advocate for the addition of alerts or reminders that would improve patient care
interprofessional patient care
o Improved communication between team members
o Increased quality and accuracy of information
o Increased opportunity for interprofessional collaboration
electronic health records and therapeutic relationships
there is potential for clinical systems like electronic health records to both support and hinder the nurse-patient relationship
increase or support patient involvement in care
o Use of trending and integrating EHRs with PHRs allows for increased participation of the patient in their health
o In order to support this involvement, nurses should: teach specific self-management activities, provide on-going support as challenges arise, recommend seeking professional care when a health concern requires professional intervention
recommendations to support the therapeutic relationship
o Connect = use eye contact, names, ask about symptoms instead of relying on what has been recorded
o Collaborate = ensure screen is not hidden, ask permission to document during the interaction, explain what you are doing when you access information in the HER, as the patient for their thoughts on the information
o Close = remind the patient about privacy information, review main findings, finish with eye-contact
