Who needs to know?
How does nursing informatics improve patient safety?
By reducing errors through accurate, timely access to patient data.
What should you never do with your password?
Share it with others.
What is the purpose of HIPAA?
To protect patient privacy and confidentiality.
It’s acceptable to erase an error in a patient's chart.: True or False
False-errors must be corrected with a single line and initial.
How does informatics enhance communication among health care providers?
Through shared electronic health records that allow real-time updates.
When charting in the EMR, there will often be "charting by exception." This type of charting is considered best because of what?
The fact that it improves the quality of documentation.
When charting for a patient who has been discharged, what essential information is required? (3 items)
Time of discharge
Mode of Transportation
Who was with them
When is it appropriate to accept a telephone order?
Only in urgent situations when the provider cannot document directly.
What is the primary purpose of a health care record?
To communicate patient care between providers.
What must the nurse do immediately after receiving a telephone order?
Read back the order to verify accuracy.
TORB
How do health records support continuity of care?
They track history, treatments, and progress over time.
A patient makes a statement like "I know I am going to die tomorrow."
How is the correct way to chart this?
Patient stated, " I know I am going to die tomorrow."
As a nurse, your responsibility for reimbursement while charting includes what?
Painting a complete picture of all the treatments that the patient is getting and how they are responding to them. Using specifics
Examples, measurements, colors, smells, descriptions.
Documentation should be what five things?
Factual, accurate, complete, current, organized.
How do health records support legal accountability?
They provide evidence of care delivered.
If it's not charted, it didn't happen!