Chapter 26: Informatics and Documentation
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Questions and Answers

What does the term 'clinical judgment' represent?

Observed outcome of critical thinking + decision making

Circular transactional model of communication includes factors like sender, message, and feedback.

True

Which form of communication involves a healing relationship between a nurse and a patient?

  • Competent communication
  • Interpersonal communication
  • Therapeutic communication (correct)
  • Intrapersonal communication

    • Match the following components of the Circular Transactional Model of communication with their definitions:

    <p>Sender = Person who initiates communication Feedback = Message a receiver receives from the sender Referent = Factor motivating communication Message = Information conveyed by the sender</p> Signup and view all the answers

    ______ is a technique that encourages patients to share their thoughts, goals, beliefs, fears, and concerns.

    <p>Motivational interviewing</p> Signup and view all the answers

    What is the main purpose of documentation in healthcare?

    <p>Supporting the process of quality improvement</p> Signup and view all the answers

    Electronic Health Record (EHR) is an individual's __________ computerized record.

    <p>lifetime</p> Signup and view all the answers

    What does the acronym PHR stand for in healthcare documentation?

    <p>Protected Health Information</p> Signup and view all the answers

    Confidentiality is an essential aspect of maintaining the privacy of health records.

    <p>True</p> Signup and view all the answers

    What is the main role of the American Recovery and Reinvestment Act (ARRA) in healthcare?

    <p>Health Information Technology for Economic and Clinical Health Act (HITECH)</p> Signup and view all the answers

    Match the following healthcare documentation forms with their descriptions:

    <p>Admission nursing history form = Records patient's medical history upon admission Patient care summary = Summarizes the care provided to the patient Care plans = Outlines the care and treatment plan for the patient Discharge summary forms = Details the patient's status and instructions upon discharge</p> Signup and view all the answers

    What is the primary function of Clinical Decision Support Systems (CDSS) in healthcare?

    <p>Assisting with clinical decision-making</p> Signup and view all the answers

    Morals refer to the study of the ideals of right and wrong behavior.

    <p>False</p> Signup and view all the answers

    What is the main principle behind Deontology in ethics?

    <p>duty to do what's right</p> Signup and view all the answers

    What is the primary purpose of documentation in healthcare?

    <p>To track a patient's clinical course</p> Signup and view all the answers

    Electronic health records (EHR) contain the lifetime computerized record of an individual.

    <p>True</p> Signup and view all the answers

    What is the purpose of the American Recovery and Reinvestment Act (ARRA) related to healthcare?

    <p>Health Information Technology for Economic and Clinical Health Act (HITECH)</p> Signup and view all the answers

    ______ is the will to do good but the equal commitment to do no harm or hurt.

    <p>Nonmaleficence</p> Signup and view all the answers

    Match the approaches to ethics with their descriptions:

    <p>Deontology = Focus on adherence to rules and principles Utilitarianism = Focus on outcomes and the greater good Casuistry = Bending policies to justify preferred outcomes Feminist ethics = Basis for moral behavior on natural caring for others Ethics of care = Focus on understanding relationships and personal narratives</p> Signup and view all the answers

    What is the definition of clinical judgment?

    <p>Observed outcome of critical thinking + decision making</p> Signup and view all the answers

    What does competent communication in nursing do?

    <p>All of the above</p> Signup and view all the answers

    Critical thinking applied during patient interactions helps overcome perceptual biases.

    <p>True</p> Signup and view all the answers

    Match the following elements of the circular transactional model with their descriptions:

    <p>Referent = Factor that motivates a person to communicate with another individual. Sender = Person who initiates interpersonal communication by conveying a message. Receiver = Person to whom message is sent during the communication process. Message = Information sent or expressed by sender in the communication process. Channel = Method used to transmit a message: visual, auditory, touch. Feedback = Message a receiver receives from the sender.</p> Signup and view all the answers

    What is a broad term that refers to all factors influencing communication? Metac_____________ation.

    <p>communication</p> Signup and view all the answers

    What is the typical structure used within healthcare organizations for decision making?

    <p>Decentralized governance</p> Signup and view all the answers

    What is the primary goal of case management in healthcare?

    <p>To streamline costs and maintain quality</p> Signup and view all the answers

    What is a characteristic of a Magnet hospital?

    <p>Clinical promotion systems and evidence-based practice programs</p> Signup and view all the answers

    What is the role of the RN in healthcare?

    <p>To assess patient needs and identify mutual outcomes</p> Signup and view all the answers

    What is the goal of the Institute for Patient-and Family-Centered Care?

    <p>To identify core concepts for patient-centered care</p> Signup and view all the answers

    What is the benefit of a decentralized management approach in healthcare?

    <p>Decisions are made at the staff level</p> Signup and view all the answers

    What is the focus of the nursing team in achieving the best outcomes for patients?

    <p>All of the above</p> Signup and view all the answers

    What is the stage of the grieving process where the patient is ready to be responsible for learning?

    <p>Resolution</p> Signup and view all the answers

    What is a key aspect of autonomy in patient care?

    <p>Making independent decisions about patient care</p> Signup and view all the answers

    What is the primary goal of interprofessional collaboration?

    <p>To deliver quality, safe patient care and create a positive work culture</p> Signup and view all the answers

    What is the outcome of critical thinking and decision-making in clinical judgment?

    <p>Observed outcome of critical thinking and decision-making</p> Signup and view all the answers

    Who is responsible for making clinical decisions?

    <p>Registered nurses and other healthcare providers</p> Signup and view all the answers

    What is the purpose of interprofessional rounding?

    <p>To encourage patient and family involvement in planning care</p> Signup and view all the answers

    What is accountability in patient care?

    <p>Assuming responsibility for the outcomes of actions and omissions</p> Signup and view all the answers

    What leads to prioritizing care in patient care?

    <p>Head to toe assessment</p> Signup and view all the answers

    What is reflection in clinical judgment?

    <p>Like an instant replay</p> Signup and view all the answers

    What is the primary focus of therapeutic communication?

    <p>A healing relationship between a nurse and patient</p> Signup and view all the answers

    What is the benefit of critical thinking in communication?

    <p>It overcomes perceptual biases or stereotypes</p> Signup and view all the answers

    What is the role of the sender in the circular transactional model of communication?

    <p>To initiate interpersonal communication by conveying a message</p> Signup and view all the answers

    What is the primary goal of competent communication in nursing?

    <p>To maintain effective relationships within the entire sphere of professional practice</p> Signup and view all the answers

    What is the definition of metacognition?

    <p>A broad term that refers to all factors influencing communication</p> Signup and view all the answers

    What is the role of feedback in the circular transactional model of communication?

    <p>To provide a response to the sender</p> Signup and view all the answers

    What is the primary characteristic of intrapersonal communication?

    <p>A powerful form of communication that occurs within oneself</p> Signup and view all the answers

    What is the purpose of involving oneself in the situation being communicated?

    <p>To honestly review everything remembered about the situation</p> Signup and view all the answers

    What is the primary factor that influences communication within both the sender and receiver?

    <p>Interpersonal variables</p> Signup and view all the answers

    What is essential for effective communication in a physical environment?

    <p>Physical and emotional comfort and safety</p> Signup and view all the answers

    What type of communication involves the tone of voice dramatically affecting the meaning of a message?

    <p>Intonation</p> Signup and view all the answers

    What is a technique that encourages patients to share their thoughts, goals, beliefs, fears, and concerns?

    <p>Motivational interviewing</p> Signup and view all the answers

    What type of relationships require forming caring relationships with entire families?

    <p>Nurse-family relationships</p> Signup and view all the answers

    What is a technique used for communicating critical information among healthcare teams?

    <p>SBAR technique</p> Signup and view all the answers

    What is a form of behavior that sometimes occurs between colleagues in healthcare settings?

    <p>Lateral violence</p> Signup and view all the answers

    What is the meaning of connotative?

    <p>A word that is influenced by thoughts, feelings, or ideas</p> Signup and view all the answers

    What is the primary purpose of therapeutic communication techniques?

    <p>To encourage the expression of feelings and ideas and convey acceptance and respect</p> Signup and view all the answers

    What is the opposite of therapeutic communication techniques?

    <p>Nontherapeutic communication techniques</p> Signup and view all the answers

    What is an important consideration when adapting communication techniques to patient needs?

    <p>Culture and language</p> Signup and view all the answers

    What is one way to evaluate the success of a patient's plan of care in facilitating communication?

    <p>Through the patient's eyes</p> Signup and view all the answers

    What happens if expected outcomes for a patient's plan of care are not met?

    <p>The plan of care is modified</p> Signup and view all the answers

    Why is it important to consider sociocultural factors in patient communication?

    <p>To improve patient outcomes</p> Signup and view all the answers

    What is the primary goal of adapting communication techniques to patient needs?

    <p>To improve patient outcomes</p> Signup and view all the answers

    What is an important aspect of patient-centered communication?

    <p>Focusing on patient needs and concerns</p> Signup and view all the answers

    Study Notes

    Informatics and Documentation

    • Documentation is a key communication strategy that produces a written account of patient data, clinical interventions, and patient responses.
    • The health care record serves multiple purposes:
      • Facilitates interprofessional communication
      • Provides a legal record of care
      • Provides justification for financial billing and reimbursement
      • Supports quality and performance improvement
      • Serves as a resource for education and research
    • Electronic Health Record (EHR) vs. Electronic Medical Record (EMR):
      • EHR: individual's lifetime computerized record
      • EMR: record for an individual health care visit
    • The American Recovery and Reinvestment Act (ARRA) and Health Information Technology for Economic and Clinical Health Act (HITECH) promote the use of EHRs.

    Documentation Guidelines

    • Maintain privacy, confidentiality, and security of the health care record
      • Use passwords and firewalls to protect PHI
      • Log out or turn off screens when not in use
    • Guidelines for quality documentation:
      • Flow sheets, progress notes, and charting by exception (CBE)
      • Narrative progress notes in formats like focus charting, SOAP notes, and PIE notes
    • Common record-keeping forms within the EHR:
      • Admission nursing history form
      • Patient care summary
      • Care plans
      • Discharge summary forms

    Ethical Considerations

    • Basic terms in health ethics:
      • Morals: judgment about behavior based on specific beliefs
      • Value: deeply held personal belief about the worth of an idea
      • Bioethics: study of ethical, social, and legal issues in biomedicine
    • Code of Ethics for Nursing:
      • Advocacy: applying skills and knowledge for the benefit of another person
      • Responsibility: respecting professional obligations and maintaining competence
      • Accountability: answering for one's actions
      • Confidentiality: respecting patient privacy

    Patient Education

    • Goal of patient education: help individuals, families, or communities achieve optimal levels of health
    • Effective communication involves feedback from the sender and receiver
    • Domains of learning:
      • Cognitive: understanding and knowledge
      • Affective: attitudes and feelings
      • Psychomotor: motor skills
    • Teaching plan should consider cultural factors and include feedback mechanisms

    Managing Patient Care

    • Nursing team: works together to achieve best outcomes for patients
    • Effective team development requires:
      • Team building and training
      • Trust and communication
      • Collaborative work environment
    • Magnet hospitals:
      • Transformed culture with a practice environment that is collaborative
      • Clinical promotion systems and evidence-based practice programs
      • Professional autonomy and control over practice environment
    • Case management: coordinates and links health care services across all levels of care for patients and their families
    • Decision making:
      • Shared governance: decentralized structure with decision-making at the staff level
      • Responsibility: duties and activities employed to perform
      • Autonomy: independent decisions about patient care
      • Authority: legal ability to perform tasks and assign duties
      • Accountability: assuming responsibility for actions and outcomes

    Critical Thinking and Clinical Judgment

    • Clinical judgment: observed outcome of critical thinking and decision making
    • Clinical decision making: technicians or other assistive personnel cannot make immediate decisions
    • Reflection: purposefully visualizing a situation and reviewing everything remembered about it
    • Importance of critical thinking and clinical judgment in effective communication

    Communication

    • Competent communication: maintains effective relationships within professional practice and meets legal, ethical, and clinical standards
    • Therapeutic communication: occurs within a healing relationship between a nurse and patient
    • Critical thinking applied during patient interactions helps overcome perceptual biases or stereotypes
    • Circular transactional model of communication:
      • Referent: factor motivating communication
      • Sender: initiates communication
      • Receiver: person to whom message is sent
      • Message: information sent or expressed
      • Channels: method used to transmit message
      • Feedback: message received by sender
      • Interpersonal variables: factors within sender and receiver influencing communication

    Informatics and Documentation

    • Documentation is a key communication strategy that produces a written account of patient data, clinical interventions, and patient responses.
    • The health care record serves multiple purposes:
      • Facilitates interprofessional communication
      • Provides a legal record of care
      • Provides justification for financial billing and reimbursement
      • Supports quality and performance improvement
      • Serves as a resource for education and research
    • Electronic Health Record (EHR) vs. Electronic Medical Record (EMR):
      • EHR: individual's lifetime computerized record
      • EMR: record for an individual health care visit
    • The American Recovery and Reinvestment Act (ARRA) and Health Information Technology for Economic and Clinical Health Act (HITECH) promote the use of EHRs.

    Documentation Guidelines

    • Maintain privacy, confidentiality, and security of the health care record
      • Use passwords and firewalls to protect PHI
      • Log out or turn off screens when not in use
    • Guidelines for quality documentation:
      • Flow sheets, progress notes, and charting by exception (CBE)
      • Narrative progress notes in formats like focus charting, SOAP notes, and PIE notes
    • Common record-keeping forms within the EHR:
      • Admission nursing history form
      • Patient care summary
      • Care plans
      • Discharge summary forms

    Ethical Considerations

    • Basic terms in health ethics:
      • Morals: judgment about behavior based on specific beliefs
      • Value: deeply held personal belief about the worth of an idea
      • Bioethics: study of ethical, social, and legal issues in biomedicine
    • Code of Ethics for Nursing:
      • Advocacy: applying skills and knowledge for the benefit of another person
      • Responsibility: respecting professional obligations and maintaining competence
      • Accountability: answering for one's actions
      • Confidentiality: respecting patient privacy

    Patient Education

    • Goal of patient education: help individuals, families, or communities achieve optimal levels of health
    • Effective communication involves feedback from the sender and receiver
    • Domains of learning:
      • Cognitive: understanding and knowledge
      • Affective: attitudes and feelings
      • Psychomotor: motor skills
    • Teaching plan should consider cultural factors and include feedback mechanisms

    Managing Patient Care

    • Nursing team: works together to achieve best outcomes for patients
    • Effective team development requires:
      • Team building and training
      • Trust and communication
      • Collaborative work environment
    • Magnet hospitals:
      • Transformed culture with a practice environment that is collaborative
      • Clinical promotion systems and evidence-based practice programs
      • Professional autonomy and control over practice environment
    • Case management: coordinates and links health care services across all levels of care for patients and their families
    • Decision making:
      • Shared governance: decentralized structure with decision-making at the staff level
      • Responsibility: duties and activities employed to perform
      • Autonomy: independent decisions about patient care
      • Authority: legal ability to perform tasks and assign duties
      • Accountability: assuming responsibility for actions and outcomes

    Critical Thinking and Clinical Judgment

    • Clinical judgment: observed outcome of critical thinking and decision making
    • Clinical decision making: technicians or other assistive personnel cannot make immediate decisions
    • Reflection: purposefully visualizing a situation and reviewing everything remembered about it
    • Importance of critical thinking and clinical judgment in effective communication

    Communication

    • Competent communication: maintains effective relationships within professional practice and meets legal, ethical, and clinical standards
    • Therapeutic communication: occurs within a healing relationship between a nurse and patient
    • Critical thinking applied during patient interactions helps overcome perceptual biases or stereotypes
    • Circular transactional model of communication:
      • Referent: factor motivating communication
      • Sender: initiates communication
      • Receiver: person to whom message is sent
      • Message: information sent or expressed
      • Channels: method used to transmit message
      • Feedback: message received by sender
      • Interpersonal variables: factors within sender and receiver influencing communication

    Patient Care Management

    • Resolution in the patient care process involves expressing emotions openly, realizing the impact of illness, asking questions, and taking responsibility for learning.
    • Acceptance involves actively pursuing information and striving for independence.

    Nursing Team

    • A strong nursing team works together to achieve the best outcomes for patients, requiring team building, training, trust, communication, and a collaborative workplace.
    • Magnet hospitals have a transformed culture, clinical promotion systems, research-based practice, and evidence-based practice programs, providing nurses with professional autonomy and control over their practice environment.

    Case Management and Decision Making

    • Case management coordinates healthcare services across all levels of care, streamlining costs and maintaining quality.
    • Decision making involves shared governance, responsibility, autonomy, authority, accountability, and staff involvement.

    Interprofessional Collaboration and Rounding

    • Interprofessional collaboration occurs among nurses and healthcare providers, aiming to deliver quality, safe patient care and create a positive work culture.
    • Interprofessional rounding encourages patient and family involvement in planning care, promoting coordination and communication among the healthcare team.

    Head to Toe Assessment and Prioritizing Care

    • Head to Toe assessment leads to prioritizing care and making clinical judgments.
    • Clinical judgment is the observed outcome of critical thinking and decision making.

    Critical Thinking and Clinical Judgment

    • Clinical judgment involves observing outcomes, making decisions, and taking action.
    • Technicians or assistive personnel cannot make decisions or take immediate action.

    Reflection and Competent Communication

    • Reflection involves visualizing a situation, reviewing, and learning from it.
    • Competent communication maintains effective relationships, meeting legal, ethical, and clinical standards of care within the entire sphere of professional practice.

    Types of Communication

    • Therapeutic communication occurs within a healing relationship between a nurse and patient.
    • Intrapersonal communication is self-talk, a powerful form of communication that helps nurses relate to others.
    • Interpersonal communication is one-on-one interaction between a nurse and another person, occurring face-to-face or via text or electronic format.

    Critical Thinking and Overcoming Biases

    • Critical thinking applied during patient interactions helps overcome perceptual biases or stereotypes that interfere with accurately perceiving and interpreting messages.

    Circular Transactional Model of Communication

    • The circular transactional model includes the referent, sender, receiver, message, channels, context or environment, feedback, and interpersonal variables.

    Verbal Communication

    • Vocabulary, denotative and connotative meaning, pacing, intonation, clarity, and brevity are essential for effective verbal communication.
    • Timing and relevance are critical for effective communication.

    Metacommunication and Motivational Interviewing

    • Metacommunication refers to all factors that influence communication.
    • Motivational interviewing encourages patients to share their thoughts, goals, beliefs, fears, and concerns.

    Nurse-Family Relationships and Nurse-Health Care Team Relationships

    • Nurse-family relationships require forming caring relationships with entire families in community and home care settings.
    • Effective communication with the healthcare team affects patient outcomes, patient safety, and the work environment.

    Communication Techniques and Lateral Violence

    • SBAR technique is used for communicating critical information.
    • Lateral violence, or bullying, between colleagues can occur and negatively impact communication.

    Therapeutic and Nontherapeutic Communication Techniques

    • Therapeutic communication techniques encourage the expression of feelings and ideas and convey acceptance and respect.
    • Nontherapeutic techniques discourage further expression of feelings and ideas and engender negative responses.

    Sociocultural Considerations and Speech and Language

    • Culture influences thinking, feeling, behaving, and communicating.
    • Speech and language considerations are essential for effective communication.

    Patient Outcomes and Evaluation

    • Patient outcomes are influenced by various factors, including communication techniques and cultural considerations.
    • Evaluation involves determining a patient's perception of the success of the plan of care and modifying the plan as needed.

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    Description

    This quiz covers the importance of documentation in healthcare, including its purposes and benefits for patient care and interprofessional communication.

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