Informatics & Documentation

Potter & Perry Ch. 26

Accreditaition

Health care agencies usually incorporate accreditation standards into policies and revise documentation systems and forms to suit these standards

• Documentation needs to conform to the standards of the National Committee for Quality Assurance and accrediting bodies such as TJC to maintain agency accreditation and to minimize liability

• Require all patients admitted to a health care agency to be assessed for physical, psychosocial, environmental, self-care, spiritual, cultural, knowledge level, and discharge planning needs

Acuity Rating System

Used to determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours

• A patient’s acuity level, usually determined by the assessment data an RN enters into a computer program, is based on the type and number of nursing interventions required by that patient over a 24-hour period

• Not part of a patient’s health record, nursing documentation within the health record provides evidence that supports the assessment of an acuity rating

Case Management

Incorporates an interprofessional approach to delivery and documentation of patient care

Charting by Exception (CBE)

All standards for normal assessment findings or for routine care activities are met unless otherwise documented 

• Exception-based documentation systems incorporate standards of care and use clear, predefined statements for the nursing documentation or “normal” body system findings 

Clinical Decision Support System (CDSS) 

A computer program that aids and supports clinical decision-making 

• Knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions to generate tailored recommendations for individual patients; the recommendations are presented to health care providers as alerts, warnings, or other information for consideration

• Improve nursing care

Clinical Information System (CIS)

• AKA patient care information system

• A large computerized database management system that accesses patient data needed to plan, implement, and evaluate patient car 

• Include monitoring systems, order entry systems, and laboratory, radiology, and pharmacy systems 

Clinical Practice Guideliens (CPGs)

• AKA standardized care plans

• Facilitate the creation and documentation of a nursing and/or interprofessional plan of care

• Each standardized plan facilitates safe and consistent care for an identified problem by describing or listing agency standards and evidence-based guidelines thatare easily accessed and included within a patient’s EHR 

Computerized Provider Entry Order (CPOE)

A system that allows health care providers to directly enter standardized, legible, and complete orders for patient care into a health record from any computer in the HIS 

• Advanced CPOE systems have built-in clinical decision support tools and alerts to help a health care provider select the most appropriate medication or diagnosist test and automatically check for drug interactions, medication allergies, and other potential problems 

Critical Pathways

• AKA clinical pathways, practice guidelines or CareMap tools 

• Interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame 

• Document facilitates integration of care because all members of the health care team use the same document to monitor a patient’s progress during each shift 

• Improve patient outcomes, improve adherence to evidence-based guidelines 

Diagnosis-Related Groups (DRGs)

Classifications based on a patient’s primary and secondary medical diagnoses that are used as the basis for establishing Medicare reimbursement for patient care provided by a health care agency 

Documentaion

A key communication strategy that produces a written account of petinent data, clinical decision and interventions, and patient responses in a health record 

Electronic Health Record (EHR)

• Health record

• Facilitates communication among health care providers

• Improves patient safety

Electronic Health Record System 

• Promotes interoperability 

• Improved quality, safety, and efficiency of health care

• Increases health care consumers’ active involvement in their care

• Increases coordination of health care delivery

• Advances public health

• Safeguards the privacy and secuirty of personal health records

Electronic Medical Record (EMRs) 

Digital version of patients’ paper charts that contain their medical history, conditions, treatments, and test results

• Improve the quality of care, reduce medication errors, and provide instant, secure access to information for authorized users

Firewall

A combination of hardware and software that protects private network resources from outside hackers, network damage, and theft or misuse of information

• Protect patient information 

Flow sheets

• Nurses routinely document patient physiological data and routine care using flow shets (graphic records) that are organzied by body system and navigated throught use of the computer mouse with a series of tabs or rows

• Allow for quick and easy entry of assessment data

• Facilitat the documentation of routine, repetitive care, and safety checks

Health Care Informatics 

Nursing competence in this is a priority because of the wide usage of electronic documentation among health care providers and agencies across the United States

• Informatics competencies to deliver safe and efficient care and to facilitate the implementation of EBP

Health Care Information System

• AKA hospital information system 

• Consists of clinical systems and / or systems needed for business operations 

• Both types of systems operate to make the entry and communication of data and information more efficient 

Health Information Technology

The use of information systems and other information technology to document, monitor, and deliver patient care and to perform managerial and organizational functions in health care 

• The focus of HIT is the patient and the process of care, and the goal of using HIT is to enhance the quality and efficiency of care provided 

Health Record

A vital aspect of nursing practice

• All information is documented into a health record 

• May be electronic, paper, or both 

• Reflect current standards of nursing practice and minimize the risk of errors 

Incident Report 

• AKA Occurrence report

• Complete whenever an incident occurs

• Analysis of incident reports helps to identify system and/or individual human issues in which educational or in-service programs or changes in policies and procedures are needed to reduce the risk of future occurrences

Meaningful Use

Refers to the US government standards for how healthcare providers use electronic health records to improve quality, safety, and efficiency

Narrative Documentaion

A format used by nurses and health care providers to document patient assessment, clinical decisions, and care provided

• Consists of a storylike format to document information

Nursing Clinical Information System (CIS)

A digital tool that centralizes and manages patient data to improve the quality, efficiency, and safety of care 

Nursing Informatics 

The specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing and informatics practice 

• Recognized as a specialty area of nursing practice at the graduate level 

• Nurses who specialize in informatics have advanced knowledge in information management and demonstrate proficiency with informatics to support all areas of nursing practice, including QI, research, project management, and system design 

Password

A collection of alphanumeric characters and symbols that a user types into a computer sign-on screen before accessing a program after the entry and acceptance of an access code or username

• Protect patient information

• Do not share passwords 

Protected Health Information

Under HIPAA is the Security Rule, which specifies administrative, physical and technical safeguards for 18 specific elements of protected health infomration in electronic form

Variances 

Unexpected outcomes and interventions not specified within a critical pathway 

• Occurs when the activities on the critical pathway are not completed as predicted, or a patient does not meet the expected outcomes 

• Sometimes results from a change in the patient’s health or because of other health complications not associated with the primary reason the patient requires care