HIPAA
TRUE or FALSE
You should NEVER share your password with co-workers?
TRUE
True or False: Documentation impacts the hospital's finances.
TRUE. Accurate documentation is necessary for hospitals to be reimbursed by Medicare or Medicaid according to diagnosis-related groups (DRGs).
TRUE OR FALSE
Documenting in a computer system provides us with better data, but it also increases the time nurses spend on documentation.
FALSE
True or False
Informatic technology eliminates the need for nursing verification.
False
Technology has errors - we need to still verify information and use technology to advance patient safety.
A patient is confused about a new medication they are prescribed. How can the nurse use technology in this situation?
Print education information -
Most EHRs have access to patient education data bases for diagnoses and pharmacology. Discharge instructions can be printed for patients as well.
While at clinical, Sarah posted a picture on social media. Can this breach patient confidentiality?
Yes, can have private information!
Guidelines that help avoid problems using social media include no transmission of any patient’s image; no posting of any patient information, including names or other identifiers; no disparaging comments about any patients or staff; and no contact with patients outside of the work setting. Report any breach immediately for quick resolution.
List 2 legal or ethical considerations for documentation.
*The medical record is the legal documentation of care provided to a patient.
• In the event of litigation, the medical record is often the only available evidence of the event in question.
• Medical record documentation should be based on fact, not opinions.
• Every entry in a medical record must include a date, time, and signature with credentials, which is recorded automatically in the electronic health record (EHR).
• Ethical practice dictates that nurses document only interventions that are performed.
• Medical record entries cannot be altered or obliterated in the EHR. If information is corrected in the EHR, the new information is visible on the screen view but the correction process is still part of the permanent medical record.
Point care documentation. The ability to document at the point of care supports the goals of timeliness and accuracy of documentation.
Provide 1 example of how point of care documentation can occur:
Computers in each patient’s room and mobile devices such as computer tablets, or workstations on wheels (WOWs) that can be rolled to a patient’s bedside
When administering medication, what technology can the nurse use to reduce patient identification errors?
bar-code medication administration (BCMA) system is used as part of the process of medication administration, fewer errors are made.
A new nurse is struggling with time management. What informatics tool can she use to help with organization?
worklist
Nursing measures can be organized according to the time they are due or the type of task (Fig. 15.5). Use of work lists helps ensure that important patient care and medication administration are carried out at the appropriate times
TRUE OR FALSE
Electronic Health Records increase the risk for private patient information to be breached?
FALSE
What is the difference between a EMR and EHR?
The electronic medical record (EMR) is a record of one episode of care, such as an inpatient stay or an outpatient appointment. The electronic health record (EHR) is a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings
The focus of nursing informatics is not on direct patient care but rather on how the process of patient care can be improved and patient safety ensured. List 2 challenges to advancements in IT:
1. increased amount of time spent documenting
2. cost of equipment
3. protection of patient privacy
4. use of different EHRs in different facilities
5. resistance by health care providers to new technology.
What is the primary goal of the clinical decision support system?
to leverage data and the scientific evidence to help guide appropriate decision making
Computerized decision support systems (DSSs), sometimes called clinical decision support systems, include safe practice alerts and reminders that improve the quality of care. Some DSSs assist in determining a correct diagnosis and choosing an appropriate medication
*think of them as safety alerts!
An alert appears on the screen when a provider is ordering amoxicillin for a patient with an infection. The provider quickly dismisses the alert and signs the order. The patient has a penicillin allergy. This an example of a possible limitation in what 2 informatic technologies?
Computerized clinical decision support systems (CDSSs) & Computerized provider order entry (CPOE).
Together can Cross-checks for drug allergies and drug–drug interactions; and may suggest laboratory tests, depending on the drugs ordered
List 1 possible outcome for a nurse who breaches patient confidentiality/
A nurse who engages in unprofessional conduct or breaches confidentiality may be
1. sanctioned by the state board of nursing
2. risk of permanent loss of one’s nursing license.
List 3 things you may document as a nurse.
Assessment findings
Care Plan
Notes
Documentation should be factual, accurate, and nonjudgmental, with proper spelling and grammar. Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation.
List 3 ways that nursing informatics teams can help improve the nurses job flow:
1. Promote real time charting - allows for IMMEDIATE REVIEW
2. Provide clear direction for appropriate documentation necessary for billing & continuation care.
3. Promote communication between interdisciplinary team members, and even different organizations
4. Multiple people can access the same chart at the same time
5. Design, and data can be analyzed and improved when needs are identified.
List 3 benefits of Computerized provider order entry (CPOE):
Computerized provider order entry (CPOE):
1. allows orders to be directly communicated to the appropriate department—diet orders to dietary, medication orders to the pharmacy, laboratory orders to the laboratory. Eliminate transcriber error
2. decreases the potential for errors related to the ambiguity of handwritten orders
3. allows quicker responses by appropriate departments.
4. reduce errors in ordering Legibility and availability of computerized documentation improve provider communication.
Disadvantages of CPOE include workflow issues, ability to bypass safety features, provider resistance to new technology, use of nonstandard terminology, and overdependence on technology
A RN has decided to become a travel nurse. She was nervous about learning a new documentation system, but has reported that it has not been as challenging as she was expecting. What aspect of informatics do you think attributed to her positive transition?
standardized language
ensures that when a nurse talks about a specific patient problem, another nurse fully understands the problem.
The use of standardized terminologies promotes consistent documentation and allows the description and comparison of nursing care across a variety of settings, facilitating measurement of the impact of nursing interventions on patient outcomes
The nurse’s notes may be in a narrative format or in a problem-oriented structure such as the PIE, APIE, SOAP, SOAPIE, SOAPIER, DAR, or CBE format.
What is telehealth and how can it be beneficial?
Remote healthcare that can be done via video, phone call, or with use of healthcare technology equipment.
It can help provide care for those not in close access to specialty care. It can help with ongoing monitoring and prevent re-occurring hospitalizations. Should not be used for acute cases such as CHEST PAIN/ RESP distress.
True or False? Having access to review other nurse and providers documentation decreases patient safety because too many staff members copy from previous documentation.
False! We should never copy or document anything we did NOT access ourselves. We can however, review previous documentation and identify changes and can use to understand if a client is improving or deteriorating and adjust the plan of care accordingly. This improves safety.