S3 M5 Information Tech Flashcards
What defines meaningful use
Improve healthcare Reduce disparities Engage pt/fam Improve coordination Maintain privacy
Steps in the system development lifecycle
Analyze/plan
Design
Test
Train
Implement
Maintain
Evaluate
Telehealth
use of tech to support care
Computerized care plan
Software that streamlines setting goals, listing causes and relevant interventions
HIE
Health info exchange
Allows providers access to other providers info for same patient
SOAPIER
Subjective Objective Assessment Plan Intervention Evaluation Response
Ethical dilemma vs moral distress
Ethical dilemma - cant pick the best option
Moral distress - cant follow through with the best option
Informed consent is not possible to sign if you have or are
Altered mental status
Minor age
Boundary crossing
Boundary violation (involves what organization)
Sexual misconduct
Caution
Danger, violation of HIPPA
FORBIDDEN
Under involvement with patient
Distance from PT
Fail to meet needs
Spend more time with staff than PT
Over involvement with patient
Discussing personal info with pt
Tell/keep pt secrets
Assume role of “super nurse”
Spend time with pt outside of work
Social media violations
Photos
Anything HIPPA related
Company badmouthing
Board of nursing exists to protect the
PATIENT
Clinical info system
Catch all term for EHR EMR etc.
Super user
Nurse who specializes in System Support
INS
Informatics Nurse Specialist
Helps with tech side of shit
Graduates degree
SDLC
System development lifecycle
Analyze and plan Design and build Test Train Implement Maintain Evaluate
Analyze and plan questions
What is the purpose
What are we solving
Is it useful
Test questions
Unit test Function test Integration test Performance test USER ACCEPTANCE testing
Clinical decision support system
like nurse advice line
variety of tools that assist healthcare team members in making decisions
Walks you through the assessment to guide you to a decision
CDSS types
Computer alerts Clinical guidelines Focused patient data report Documentation templates Diagnostic support
CDSS need to do what
Give right info To the right person Through the right channels In the right format At the right point in workfrlow
Right info
evidence based
Right people
team+patient
right channels
med record
mobile device
patient portal
Computer reminder system
Timeliness of interventions
Allergy alerts
Appointment alerts
Teaching alerts
Keeping info secures
Dont share passwords, dont reuse make it easy to remember but hard to guess at least 8 characters use multiple authentications use password manager
Telehealth, telemedicine, telecare
using electronics so patients and providers can reach each other
Alarm fatigue
desensitization to hearing or recognizing alarms
Alarms are a requirement for
accreditation
Sentinel even alert in terms of alarms
Alarms are silenced or turned down.
Contributes to PT death
Comes from not using correctly or not responding
Alarms issues are associated with what nursing
Critical Care
Alarms are disabled by
Nurses and patients/family
Health record is a _ document
legal
document facts, no oppinions
info in med records should be
OBJECTIVE
not subjective
USE QUOTES if pt refuses care, let PROVIDER know
Document same time as
assessment or treatment
Adverse event documentation is established by
Established by Risk management team
document what happened etc.
How to safely chart
Use good passwords
Don’t leave work station open, HIPPA
How to correct mistakes in documentation
Narrative note of what happened why and what is going on
Due to safeguards of med records
Things can not be deleted
if they are, let supervisor know
Dont use email to send
Personal health info
If you have to, ENCRYPT
