Health informatics

introduction

documentation

Documentation standards

elements of documentation

legal guidelines

flow charts

Show trends in vital signs, glucose, pain, and other frequent assessments.

narrative notes

Record events in a story-like sequence.

charting

by exception: Document only deviations from established norms.

electronic health records

Standardized, accurate, and confidential.

change of shift

Face-to-face, audiotaped, or bedside handoff.

telephone

Provide accurate data, document names, times, and instructions.

telephone prescription

Repeat back, have second nurse listen, provider signs within 24 hr

transfer

Include demographics, diagnosis, plan of care, recent progress, and critical updates.

incident reports

information security

protocols

health record components

EHR advantages

documentation methods

source oriented

SOAP

PIE

focus charting

charting by exception

electronic documentation

EHR Downtime

documentation guidelines

Hitech act

encouraged use of Computerized Provider Order Entry (CPOE).

CPOE

minimizes medication errors, provides clinical decision support, and ensures quick, safe prescription transmission.