Care: informatics

informatics

Science that encompasses information science and computer science to study the process, management and retrieval of information

healthcare informatics

Application of computer technology and information science and basic biomedical sciences to facilitate the acquisition, storing, analyzing (processing and interpretation) to allow optimal use and dissemination (communication) of health-related data

nursing informatics

Use of information and computer technology to support all aspects of nursing practice, including direct delivery of care administration education and research

intended consequences of informatics

By computerizing health records we can avoid dangerous medical mistakes, reduce costs and improve care

what are the six aims for healthcare

 Safe (preventing injury or adverse outcomes to our patient)

 Effective-using technology (ensuring evidence based actions are being done)

 Patient- centered( patient preferences, needs and values are considered)

 Timely-care when needed

 Efficient-cost effective care (making sure we are not wasting supplies)

 Equitable-for all people

Unintended consequences of informatics

defined as positive, negative, or neutral unanticipated outcomes occurring as a result of a planned activity or event. Thus, it is important to consider the potential unintended consequences that may be produced by adoption of health IT

Hippa and informatics

HIPAA Concerns-could be a result of informatics

Privacy-

• Only with people involved in the patient care case

• Never take-home patient information/ hippa info

• Never use identifiers on assignments

Security-only use your own password and ID. Document ONLY what you did.

documentation accuracy and informatics

Documentation Accuracy

Complete, Current, , factual, accurate, organized, and Concise

• Use approved abbreviations and within the facilities

documentation is

written account of nursing process

bad documentation

affects patient care

Basic Clinical Applications

-Computerized providers order entry

-Clinical decision support system (CDSS)

-Electronic Medication administration records

-Barcode Medication administration

-Clinical documentation

NANDA abbreviations

nursing diagnosis

NIC abbreviations

Nursing Interventions Classifications

NOC abbreviation

Nursing outcomes classification

PNDA

Perioperative Nursing Data Set –diagnosis , interventions, outcome

what are QSEN competencies/ national patient safety goals used for

to provide standards of care to nursing. Both provide guidelines and examples of care for nursing students and registered nurses. These standards are widely used within a variety of hospital settings.

informatics…

-Protect confidentiality (Secure patient data across care teams)

-Document appropriately in Electronic Health Record (Allows objective documentation to be shared across care teams)

-Use communication technologies to coordinate patient care (Gives the team access to electronic health records and clinical guidelines quickly)

-Respond correctly to clinical decision-making alerts. (Alerts and system safeguards help to prevent mistakes and possible errors)

use of information and tech and nursing students

to communicate, manage knowledge, mitigate error, and support decision making, outline specific skills and attitudes that nursing students need to learn to use informatic technology and provide patient care in a n effective and safe manner

what does nursing informatics integrate

nursing computer, informatic science to manage and communicate data info knowledge in nursing and informatics practice

main goal of healthcare informatics

patient and process of care

what does computerized health records/ informatics help improve

healthcare providers workflow by decreasing BLANK? and increasing administrative effectiveness which allows us to be resourceful of our supplies= reducing waste and cost

pros of computerized health records/ informatics

-can track records among healthcare team→ ensuring we are compliant with accrediting agencies

-prevents medical errors, creating cultural, social organization and intellectual changes = improvement of the quality of care

what does using standardized nursing diagnosis enable

nurses to formulate nursing diagnsis and associate interventions and to assess the outcomes in nursing care

what does using standardized nursing diagnosis provide

diagnostic clarity and effective interpersonal communication

NANDA → nursing problem from intial assessment then…

formulating outcomes with the smart goal to assist with the plan of care to promote, prevent, restore, or maintain health through assessment and intervention

Computerized providers order entry

system where providers write the orders that go to the interprofessional team in the electronic health record

clinical decision support system (CDSS)

-computer program that aids and supports clincial descion making

• contains reules and logical statments that link infor required for our clinical descion making

what does electronic medication administration record and barcode medication administration help reduce

errors with medication