Informatics

Informatics

  • Definition: The use of information and technology to communicate, manage knowledge, mitigate error, and support decision making.

  • Nursing Informatics: Integration of technology and clinical decision-making skills in nursing.

Simulation

  • Evidence-based technique to improve clinical decision-making skills in nursing students.

  • Enhances communication, leadership, and situational awareness.

  • In future simulations, Electronic Health Records (EHR) will deliver diagnostic testing results.

Clinical Information System

  • Allows instant retrieval of client information from data networks.

  • Involves bar code scanning to improve client safety and documentation.

  • Avoid overriding the system to ensure client safety.

Electronic Health Records (EHRs)

  • Digitized documentation system enhancing client care.

  • Comprehensive records of health history, treatments, and provider communications.

  • All Components of a EHR can be used as legal documentation in court.

Source-Oriented Health Record

  • Source oriented HR is a Traditional format for documentation divided into sections (history, progress notes, etc.).

  • Documentation should adhere to the FACT principle: Factual, Accurate, Complete, Timely.

Clinical Pathways

  • Order sets (PowerPlans in Cerner) standardize care delivery for specific client groups. (typically clients of the same provider )

Documentation

  • Must be clear, accurate, concise, and accessible to facilitate team communication.

Charting by Exception

  • Documents only unexpected or unusual findings; shorthand for routine documentation.

EHR Guidelines

  • Use unique login credentials; maintain password security.

  • never use anyone elses login

  • Log off after documentation; protect screen information from unauthorized viewing.

  • Ensure professional credentials are noted when using electronic signatures.

  • HIPPA

HIPAA Rules

  • Privacy Rule: Codes unique identifiers for privacy during transmission.

  • Security Rule: Avoids personal device use to prevent data breaches w clients.

  • Breach Notification Rule: Clients notified within 60 days after breach discovery. notify via email asap.

  • Enforcement Rule: Involves compliance, investigation of violations, and penalties.

Health Literacy

  • Healthy People 2020 names health literacy as a subheading to the socialdeterminant of health and health care.

  • Defined as an individual’s ability to obtain, process, and comprehend health information.

  • Organizational health literacy addresses how organizations help individuals with health-related decisions.

Information Management Technology

  • Supports completion of tasks (medication barcodes, smart infusion pumps).

  • Not a substitute for clinical decision-making; overrides should be cautious to prevent errors.

  • Nurses can override alerts, but should not in order to prevent errors fromoccurring