informatics

purpose of documentation

• interprofessional communication

• legal record

• justification for billing

• auditing

• education

• research

privacy

legally and ethically obligated to keep all info confidential

shred when no longer need + de-identify

documentation guidelines

• factual

• accurate

• current

• organized

• complete

documentation methods

• narrative - story like

• focus - focus on patient concerns

  • data action response

• SOAP - problem oriented

• chart by exception - only document abnormal findings

• PIE - focused on nursing process

  • problem, intervention, evaluation

• SBAR - used in communication between staff

  • situation, background, assessment, recommendation

telephone and verbal orders

• must read back

• write down order immediately

  • date, time, provider name, your name

• provider must sign within 24 hours

acuity rating system

determine patient care needs and staffing needs

higher score = higher acuity = more intensive care needed

informatics

combine nursing science, info and computer science to manage data

HIS - health care information system

software that is used

CIS - clinical information system

other monitors and tools used

• bedside monitors

• pyxis

• infusion pumps

NCIS - nursing clinical information system

helps with documentation

• care planning tools

• documentation (charting)

CDSS - clinical decisions support system

helps make clinical decisions

• provides alerts, reminders, recommendations