Nurs 250 Exam 2 (Ch. 10,11,15)

Computerized provider order entry (CPOE)

allows orders to be directly communicated to the appropriate department

computerized clinical decision support systems (CDSSs)

are usually paired with CPOE

information

organized data

knowledge

organized information that is meaningful

mobile technology provides nursing students and nurses with instant access __________

to safe dose, compatibility and pharmacokinetic information

Telehealth or telemedicine

the use of the internet to link medical experts with other clinicians, allowing remote consultations with clear video images and high-fidelity links

the use of telemonitoring offers the opportunity to _________

reduce the cost of health care while improving outcomes and pt satisfaction

which term simply means "organized data"?

A. wisdom

B. knowledge

C. informatics

D. information

D. information

treatment decisions are based on

information derived from data

use of health care IT has improved

organization, communication, and decision making; reduced duplicate orders, charting time, and paperwork; made medication administration safer; and enhanced information access and administrative functions

Bar Code Medication Administration (BCMA)

An electronic system of administering medication that makes use of specific bar code identifiers for each medication (fewer errors are made)

computerized decision support system (DSSs)

include safe practice alerts and reminders that improve the quality of care

informatics

broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science

Nursing informatics

a specialty area of informatics that addresses the use of health information systems to support nursing practice

nurses must ensure the

accuracy of recorded data

documentation should occur on _________

a timely basis

data

facts

wisdom

appropriate application of knowledge

WOWs

workstations on wheels

what is the most obvious advantage of mobile technology

prevention of medication errors

Electronic Health Record (EHR)

is a longitudinal record of care

analysis and comparison of electronically captured health data identifies

evidence to support nursing practice

the hared global computing network of the internet

provides connections with many kinds of resources that can be useful in the delivery of nursing care

Listserv

a computer program that automatically sends messages to multiple e-mail addresses on a mailing list

blog

social medium that is usually maintained by an individual and has regular entries of commentary, descriptions of events, or other material such as graphics or videos

nursing informatics beginner skills

-computer, information, erb literacy

-fundamental skills in information management

-the ability to identify and collect relevant data

nursing informatics experience skills

-Able to see data relationships and make judgments based on trends and patterns in data

-Skilled in information management and the use of computer technology

-Able to suggest areas for IT system improvement

nursing informatics specialist skills

-Focus on information needs for the practice of nursing

-Integrate and applies information science, computer science, and nursing science

-Apply skills in critical thinking, data management, processing, and system development

nursing informatics innovator skills

-Conduct research and generate theory

-Develop solutions and understand the interdependence of systems, disciplines, outcomes

Nursing informatics competencies

Technical

Utility

Leadership

computer literacy

knowledge of computers and the ability to use them efficiently

information literacy

ability to recognize when information is needed and to locate, evaluate and effectively use the needed information

the Technology Informatics Guiding Education Reform (TIGER)

initiative identified a set of skills needed by all nurses practicing in the 21st century.

TIGER vision pillars include:

management and leadership

education

communication and collaboration

informatics design

IT policy and culture

TIGER vision for the future of nursing addresses

addresses informatics and emerging technologies to provide safer, patient-centered care by using evidence and technology in practice, education, and research.

Which of the following is a computer program that automatically sends messages to multiple e-mail addresses on a mailing list?

A. The Internet

B. A blog

C. A listserv

D. Telemedicine

C. A listserv

standard nursing terminology

A structured vocabulary that provides a common means of communication among nurses

Nursing Minimum Data Set (NMDS)

Represents the first attempt to standardize the collection of essential nursing data

international Classification from Nursing Practice (ICNP)

provides a standard that facilitates the description and comparison of nursing practice locally, regionally, nationally, and internationally.

ICNP was developed under the auspices of

the International Council of Nurses (ICN)

as pt advocates, nurses must be prepared to _________

to teach consumers how to evaluate the online sources of information and the information provided as they promote health literacy.

ask pts where and how they get

health-related information

explore with pts their use of _________ and how they decide whether ______

-computer

-information obtained from the Internet is reliable, accurate, and current

teach pts how to evaluate

a health-related website

Website evaluation criteria

authority, purpose, coverage, currency, objectivity, accuracy, verification

Which of the following is an advantage of standardized terminology? (Choose all that apply.)

A.It promotes consistent documentation.

B.It provides a common means of communication.

C.It enables data from different geographic regions to be compared.

D.It enables nurses to compare data across populations.

all are the answers are correct

ethics standards and guidelines for Internet health sites are

being developed and promoted by several organizations.

Health on the Net Foundation (HON)

focuses on the promotion and use of reliable online health information

The Internet of Healthcare Coalition

created to promote quality health resources online and to ensure that consumers and professionals are able to find reliable, quality information online.

The Internet of Healthcare Coalition consults with

-World Health Organization (WHO)

-U.S. Food and Drug Administration (USDA)

-U.S. Federal Trade Commission (USFTC)

to promote credible online health care information and combat online health fraud.

Nursing informatics and nursing education

-Distance learning opportunities

-Virtual realities and simulations

-Online discussion boards

-Online classrooms and support groups

-Social media sites

distance learning and opportunities

are widely available for formal degree programs and continuing education

Virtual realities and simulations

allow the learner to participate in immersion scenarios that help in the development of critical-thinking and decision-making skills

Online discussion boards

used for educational activities

Online classrooms and support groups

are used for educational activities.

Social media sites

are used for educational activities.

data security and confidentiality of

pt information are major issues

Sign-on and password codes for access to an electronic health record system must

never be shared with anyone

it is important that nurses know about

applicable laws and regulations, policies, procedures, the ethical codes of their employers, and the ethical codes of their professional organizations.

computer ethics

set of moral principles that regulate the use of computers

Computer Ethics Institute (CEI)

to serve as a forum and resource for identifying, assessing, and responding to ethical issues associated with the advancement of information technologies and to facilitate the recognition of ethics in the development and use of computer technologies.

thou shalt not use a computer to

harm other people

thou shalt not interfere with other

people's computer work

thou shalt not snoop around other

people's computer files

thou shalt not use a

computer to steal

thou shalt not use a computer to bear

false witness

thou shalt not copy or use

proprietary software for which you have not paid.

thou shalt not use other people's computer resources without

Authorization or proper compensation

thou shalt not appropriate

other people's intellectual output

Thou shalt think about the social consequences of the

program you are writing or the system you are designing

Thou shalt always use a computer in ways that

ensure consideration and respect for your yellow humans

the goal of the eHealth Code of Ethics is

"to ensure that people worldwide can confidently and with full understanding of known risks realize the potential of the internet in managing their own health and the health of those in their care"

the principles that provide the framework for this ethical code are

candor, honesty, quality, informed consent, privacy, professionalism in online health care, responsible partnering, and accountability.

the nursing profession is critical to

successful adoption of IT in health care

ability to determine the evidence of

best practice will be enhanced

increasing mobile technology will

increase access

the spread of IT supports consumer

empowerment and self-management of wellness and disease

Health Care Documentation

any written or electronically generated information about a patient

Any written or electronically generated information about a patient:

describes the pt

describe she pts health

describes care and services provided

includes data of care

purpose of health care documentation

facilitation of information flow to support continuity, quality, and safety of care

goal of health care documentation

to describe facts clearly and concisely to improve communication

Standards for documentation are established by

each health care organization's policies and procedures (Joint Commission's standards)

Principles from Centers for Medicare and Medicaid Services (CMMS)

-Completeness

-Legibility

-Reason for patient encounters

-Include assessments, diagnosis, plan of care, patient progress, any changes in diagnosis and treatment

American Nurses Association (ANA)

Professional organization that represents all registered nurses.

American Nurses Association has identified

-principles of nursing documentation related to the characteristics of documentation, education and training, policies and procedures, protection systems, entries, and standardized terminologies.

The ANA"s model for

•

for high-quality nursing documentation reflects the nursing process and includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and retrievability.

Diagnostic Related Groups (DRGs)

are a system used to classify hospital admissions.

DRG is reimbursed at a

specific rate and payment is often based on the documentation supporting the hospital stay

medical record

serves as the major communication tool between staff members and as a single data access point for everyone involved in the patient's care.

medical record contains information about

-Patient health care encounters

-Demographic, administrative, and clinical data

the medical record is the

legal documentation of care provided to a pt

in the event of litigation, the medical record is often the

only available evidence of the event in question

litigation

the process of taking legal action, lawsuit

medical record documentation should be

based on fact, not opinions

every note in a medical record must include a

date, time, and signature with credentials

ethical practice dictates that nurses document _______

only interventions that are preformed

medical record entries cannot be ________

altered or obliterated

potential problems of paper records

Can be difficult to locate

Single-user access

Fragile, susceptible to damage, can degrade

Handwriting may be illegible

Storage can be problematic

traditional guidelines

Black ink; include date, time and signature; no blank spaces

Electronic Medical Record (EMR)

a record of one episode of care