22 terms

Nursing Part 2 Informatics

Informatics: 2008 definition (ANA)
1. speciality that integrates nursing science, computer science, information science to manage & communicate data, information, knowledge & wisdom in nursing practice
informatics nurse
Informatics Nurse Specialist (graduate level)
Informatics: regulatory requirements - HIPPA
1. HIPPA 1996
- health info privacy law
- data security standards
- electronic transactions standards
Informatics: regulatory requirements - The Joint Commission (TJC)
1. adopt written privacy policies
2. protect identifiable patient health info
3. staff must know consequences of noncompliance
HIPPA mobile computing devices (5)
1. tablets, smartphones
2. careful physical control of the device
3. use data encryption to protect info
4. password
5. disable infrared ports & don't use infrared transmissions in public locations
Clinical information systems "CIS"
collection of various information technology application that provides centralized repository of info related to patient care across distributed locations
ex. patient's history of illnesses, interactions with providers...status of decisions, actions underway, genetic info, social context (married, divorced, etc)
Electronic health record "EHR" (2)
1. longitudinal, demographics, progress notes, problems, medication, treatments, immunizations, lab reports, diagnostic reports
2. 2014 electronic mandate by federal agencies (medicare)
Electronic Medical Record "EMR" (9)
1. hospital system or doctors office system
2. replaced the paper medical record
3. store & analyze patient data (for billing)
4. computerized teaching plans and care plans
5. Work lists: medications, treatments, assessments, procedures
6. document care
7. order entry
8. labs & diagnostics
9. medication records
Informatics: other issues-handheld devices
1. handheld devices to prescribe & dispense medication, electronic Rx by 2010
Informatics: other issues-CPOE
CPOE: computerized physician order system
Informatics: other issues-BCMA
bar code medication administrations (no effect in reducing errors)
Informatics: other issues- E-Health
medical informatics, literature, health services, health surveillance
-61% of american adults surf the web for health info
Informatics: other issues- Email
expanded to include communication with physicians & nurses
Point of care documentation
1. smart phones, tablets, workstation on wheels, computers at bedsides
2. reduces data latency (where are the results?) & data error (Gearing 2006)
evaluating internet resources: General (6)
1. McGonigle 2002
2. who were the authors?
3. how timely is it?
4. are the goals stated, who is the audience?
5. is the content accurate, is the site biased?
6. does the site download quickly, is it a secured site?
evaluating internet resources: CARS 2007
1. credibility-authors credentials
2. accuracy-comprehensive
3. reasonableness-fair and objective
4. support-2 other sources confirm the information
evaluating internet resources: CAFE
1. challenge information
2. adapt & require more credibility
3. file info, do not automatically believe it
4. evaluate & reevaluate - information changes
Informatics & Clinical practice: basic computer competencies (7)
1. concepts of informatics
2. using computer
3. managing files
4. word processing, spreadsheets
5. using data bases
6. presentation
7. web browsing & communication
documentation (5)
1. if it is not documented, you didn't do it
2. written/typed legal record of all interactions with the patient
3. medical records include: assessments, nursing diagnoses or patient's needs, interventions, outcomes (evaluations of interventions)
4. documentation is best defense against negligence
5. no blank spaces
safe computer charting (6)
1. never give personal password to anyone
2. do not leave terminal unattended if logged in
3. policy: correcting errors, deleting records, sensitive information
4. ensure backup files
5. do not leave patient information displayed
6. only use encrypted emails
Personal health record (5)
1. prepared on the web to manage your personal health
2. includes: medical history, diagnoses, symptoms, medications
3. you can scan in doctor's notes, test results, CT images, insurance information
4. you can share the information with other healthcare providers, family members
5. especially good when:
-chronic illness
-for caregivers of children
-aging adults with complex histories