This field combines nursing science with information technology.
What is nursing informatics?
EHR stands for this.
What is Electronic Health Record?
This type of reporting is given during shift change.
What is handoff report?
Before giving a medication, always check the "five rights". Name one.
What is right patient, medication, dose, route or time?
This type of assessment is typically performed on patient admission.
What is a comprehensive assessment?
This type of assessment targets a specific complaint or system.
What is a focused assessment?
The primary goal of nursing informatics is to improve this. (2 words)
What is patient care and outcomes
A key benefit of EHR is improved ___________ among providers.
What is communication?
An incident report is filed when this occurs.
What is an error, near miss, or adverse event?
This technology scans medications and patient wristbands for safety.
What is barcode scanning?
A comprehensive assessment includes this full body approach.
What is the head to toe assessment?
A patient with shortness of breath need this focused assessment.
What is a respiratory assessment?
The person responsible for integrating informatics into nursing practice. (2 word title)
Who is the nurse informaticist?
This feature allows clinicians to enter orders directly into the system.
What is CPOE (Computerized Provider Order Entry)?
This type of reporting helps identify system-wide risks.
What is aggregate data reporting?
A medication is given IV instead of IM. What type of error is this?
What is a route error/medication administration error?
This kind of data includes patient reported symptoms.
What is subjective data?
A neurological assessment is completed after noticing this symptom.
What is confusion or change in mental status?
HIPAA is a regulation that protects this information in informatics. (2 words)
What is patient privact and data security?
A legal risk of improper EHR documentation.
What is malpractice or liability?
The standard format often used in nurse-to-nurse communication.
What is SBAR (Situation, Background, Assessment, and Recommendation)?
This document tracks all medications given to patient.
What is the Medication Administration Record (MAR)?
Comprehensive assessmets include physical, emotional, and this type of health.
What is psychosocial (or mental) health?
This type of assessment is commonly repeated to monitor known problems.
What is a follow-up or focused reassessment?
The national initiative that promotes health IT and it's meaningful use.
What is the HITECH Act?
The process of switching from paper to electronic systems.
What is EHR implementation or digitalization?
Reporting that helps monitor performance, outcomes, and quality.
What is quality reporting or performance reporting?
You must identify a patient using these two specific identifiers.
What are full name and date of birth?
This tool or method helps guide a complete patient health history.
What is a health history form or nursing assessment tool?
A focused assessment is guided by these two things.
What are the patient's complaints and the nurse's clinical judgement?