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131 Terms
What is nursing informatics?
Using nursing knowledge, information, and technology to make safer care decisions.
What three sciences make up nursing informatics?
Nursing science, computer science, and information science.
What does nursing informatics help nurses manage?
Data, information, knowledge, and wisdom.
Why do nursing students need informatics skills?
To use health technology and client information safely.
How did Florence Nightingale use data in the 1850s?
She used it to improve sanitation.
What happened to nursing informatics in 1992?
The ANA recognized it as a nursing specialty, allowing certification.
What is nursing simulation?
Practice that feels like real client care but takes place in a safe learning setting.
What can students practice in simulation?
Assessment, decisions, skills, leadership, communication, scanning, and charting.
Why is simulation safe for students?
They can learn from mistakes without harming a real client.
Does simulation replace clinical experience?
No. It adds to clinical experience.
Why is simulation becoming more important?
Clinical sites and faculty may be less available.
What is clinical decision-making?
Assess the client, choose the priority, and use evidence-based care.
How does simulation prepare students for client changes?
They can respond in real time and see the results of their actions.
What is a clinical information system?
A computer system that helps the care team access and use client information at the point of care.
What are examples of clinical information system tasks?
Charting, entering orders, scanning armbands, and giving medications.
Why scan a client's armband before drawing blood?
To confirm the correct client.
What is venipuncture?
Drawing blood from a vein.
What is an order entry system used for?
Entering medication, procedure, and treatment orders promptly.
How long does a health care organization have to give a patient access to their requested health information?
Generally within 30 days.
What is an electronic health record (EHR)?
A digital client health record that authorized providers can update and access.
What can an EHR contain?
Health history, diagnoses, allergies, test results, and care records.
What does real-time information mean?
The information is updated and available right away.
Why are EHRs useful?
They improve safety, quick access, coordination, efficiency, and record keeping.
What does redundancy mean in health records?
Repeated or unnecessary information or work.
What is interoperability?
Different health systems can safely exchange and use client information.
What does interoperability improve?
Information sharing, client involvement, care coordination, and safety.
What can certified EHR technology support?
E-prescribing, secure information sharing, and client access to records.
What is e-prescribing?
Sending a prescription electronically from a computer, tablet, or similar device.
Why use e-prescribing?
It can make prescriptions easier, safer, and less costly to send.
What is a clinical decision support system (CDSS)?
Software that gives reliable information to help clinicians make decisions.
How can a CDSS help client care?
It supports faster decisions, diagnoses, responses, and treatment plans.
What problems can good information systems reduce?
Lost information, duplicate forms, and medication list mistakes.
What is a clinical pathway?
An evidence-based care plan for a specific condition; also called a care map.
What does a clinical pathway show?
Expected care steps and the usual course for a health problem.
Why do health systems use clinical pathways?
To improve quality and efficiency while managing costs.
What is high-value care?
Safe, effective, efficient, fair, and client-centered care.
What must nurses do for clinical pathways to work?
Accept and use them in client care.
What is quality improvement?
Making care safer, more effective, and more efficient.
What does HIPAA stand for?
Health Insurance Portability and Accountability Act.
When was HIPAA enacted?
1996.
Why does HIPAA exist?
To protect health information and prevent its improper use.
What is protected health information (PHI)?
Health information that can identify a person.
What are examples of PHI?
A client's history, test results, date of birth, address, insurance details, and Social Security number.
What is electronic PHI (ePHI)?
Protected health information stored or sent electronically.
What does the HIPAA Privacy Rule cover?
When PHI may be used or shared.
What does the HIPAA Security Rule protect?
The confidentiality, accuracy, and availability of ePHI.
What does the Breach Notification Rule require?
Reporting a PHI breach and notifying affected people.
What is a PHI breach?
Accessing, using, or sharing PHI without authorization.
What are three kinds of ePHI safeguards?
Administrative rules, technical protections, and physical security.
What are examples of technical safeguards?
Passwords, encryption, firewalls, and automatic logoff.
What are examples of physical safeguards?
Locked areas, badge access, and protection from device theft.
What are examples of administrative safeguards?
Staff training, policies, and procedures.
What rights do clients have over their health records?
They can get copies and ask for corrections.
Who should access a client's record?
Only authorized people who need it for the client's care or other permitted work.
Why might a nurse and physical therapist both access a record?
Both need relevant information to provide and document care.
What should a nurse avoid when using social media or a personal phone?
Posting client details or photos and sending PHI through unauthorized apps.
Why should a nurse close or lock an unattended EHR?
Someone else could see private information.
Where should nurses avoid discussing PHI?
Places where others may hear, such as hallways, elevators, and cafeterias.
How can poor PHI disposal cause a breach?
Paper is not shredded or ePHI remains on a reused or discarded device.
What should a nurse know before putting client data into an app?
Where the data goes, who can access it, and who owns it.
What are five common HIPAA violations in the material?
Unauthorized access, poor disposal, denying access, improper sharing, and lost PHI.
When may client information need to be reported by law?
For certain communicable diseases, injuries, or law enforcement needs.
Why must nurses be careful with an adolescent's records?
Some information may be confidential from parents under applicable rules.
Who investigates HIPAA complaints?
The Office for Civil Rights (OCR).
What can happen after a serious HIPAA violation?
Corrective action, a civil penalty, or criminal penalties in some cases.
What does a privacy officer do?
Oversees privacy policies, training, and privacy incidents.
What does a security officer do?
Oversees the protection of electronic PHI.
How often does this course material say HIPAA training occurs?
Yearly.
When must affected people generally be notified of a reportable breach?
As soon as possible and no later than 60 days after discovery.
When may encrypted ePHI be treated differently after a breach?
When the encryption makes the data unreadable and unusable.
What is telehealth?
Using technology to provide health care when the client and provider are in different places.
What can providers do through telehealth?
Assess, diagnose, treat, and help prevent illness when appropriate.
How can telehealth improve access?
Clients may receive care without traveling to an office.
What skills does a nurse need for telehealth?
Clinical judgment, clear communication, technology skills, and legal and ethical awareness.
How should telehealth skills develop?
Throughout a nurse's career, from novice to expert.
What does the course material say about RN and PN telehealth roles?
The RN assesses clients; the PN monitors clients within their role.
How can smartphones help nurses?
They can provide clinical information that supports decisions.
What is The Joint Commission?
An organization that accredits health facilities and focuses on quality and safety.
What is the focus of National Patient Safety Goal 3?
Improving medication safety.
What is medication reconciliation?
Checking and updating the complete list of a client's medications.
Why is medication reconciliation important?
It finds medication differences or mistakes before they cause harm.
When should medications be reviewed?
At admission, during care transitions, and at clinical visits.
What should a client bring to a health visit?
A current list of prescriptions, over-the-counter drugs, and supplements.
What medication details should nurses share during a care transition?
Current medications and known allergies or sensitivities.
What is an adverse drug event (ADE)?
Harm caused by the use of a medication.
What is a medication error?
A preventable mistake involving a medication.
What are the five phases of the medication process?
Prescribing, transcribing, dispensing, administering, and monitoring.
During which phases do many harmful medication errors occur?
Dispensing and administering.
What should nurses use every time they give medication?
Clinical judgment and the rights of medication administration.
How does barcode medication administration work?
Scan the client's ID band, then the medication barcode, and respond to any alerts.
What errors can barcode scanning help prevent?
Wrong client, medication, dose, or time.
Why must nurses keep learning health technology?
Systems and tools change over time.
What should nurses document?
Vital signs, assessments, medications, treatments, and procedures.
What three qualities should nursing documentation have?
It should be complete, accurate, and timely.
Why is accurate charting important?
It tells the care team what happened and provides a legal record.
How can poor charting affect care?
It can break continuity of care and lower care quality.
What is a challenge with documentation?
Charting can take time away from direct client care.
How can electronic documentation help?
It stores information quickly and can improve safety and care quality.
What is remote patient monitoring (RPM)?
Using devices to collect client data and send it to the care team from another location.
What devices can be used for RPM?
Sensors, wearables, implanted monitors, smartphones, and apps.