Chapter 26: Informatics and Documentation

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:

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

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

Motivational interviewing Signup and view all the answers

What is the main purpose of documentation in healthcare?

Supporting the process of quality improvement Signup and view all the answers

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

lifetime Signup and view all the answers

What does the acronym PHR stand for in healthcare documentation?

Protected Health Information Signup and view all the answers

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

True Signup and view all the answers

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

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

Match the following healthcare documentation forms with their descriptions:

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 Signup and view all the answers

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

Assisting with clinical decision-making Signup and view all the answers

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

False Signup and view all the answers

What is the main principle behind Deontology in ethics?

duty to do what's right Signup and view all the answers

What is the primary purpose of documentation in healthcare?

To track a patient's clinical course Signup and view all the answers

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

True Signup and view all the answers

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

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

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

Nonmaleficence Signup and view all the answers

Match the approaches to ethics with their descriptions:

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 Signup and view all the answers

What is the definition of clinical judgment?

Observed outcome of critical thinking + decision making Signup and view all the answers

What does competent communication in nursing do?

All of the above Signup and view all the answers

Critical thinking applied during patient interactions helps overcome perceptual biases.

True Signup and view all the answers

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

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. Signup and view all the answers

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

communication Signup and view all the answers

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

Decentralized governance Signup and view all the answers

What is the primary goal of case management in healthcare?

To streamline costs and maintain quality Signup and view all the answers

What is a characteristic of a Magnet hospital?

Clinical promotion systems and evidence-based practice programs Signup and view all the answers

What is the role of the RN in healthcare?

To assess patient needs and identify mutual outcomes Signup and view all the answers

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

To identify core concepts for patient-centered care Signup and view all the answers

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

Decisions are made at the staff level Signup and view all the answers

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

All of the above Signup and view all the answers

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

Resolution Signup and view all the answers

What is a key aspect of autonomy in patient care?

Making independent decisions about patient care Signup and view all the answers

What is the primary goal of interprofessional collaboration?

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

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

Observed outcome of critical thinking and decision-making Signup and view all the answers

Who is responsible for making clinical decisions?

Registered nurses and other healthcare providers Signup and view all the answers

What is the purpose of interprofessional rounding?

To encourage patient and family involvement in planning care Signup and view all the answers

What is accountability in patient care?

Assuming responsibility for the outcomes of actions and omissions Signup and view all the answers

What leads to prioritizing care in patient care?

Head to toe assessment Signup and view all the answers

What is reflection in clinical judgment?

Like an instant replay Signup and view all the answers

What is the primary focus of therapeutic communication?

A healing relationship between a nurse and patient Signup and view all the answers

What is the benefit of critical thinking in communication?

It overcomes perceptual biases or stereotypes Signup and view all the answers

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

To initiate interpersonal communication by conveying a message Signup and view all the answers

What is the primary goal of competent communication in nursing?

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

What is the definition of metacognition?

A broad term that refers to all factors influencing communication Signup and view all the answers

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

To provide a response to the sender Signup and view all the answers

What is the primary characteristic of intrapersonal communication?

A powerful form of communication that occurs within oneself Signup and view all the answers

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

To honestly review everything remembered about the situation Signup and view all the answers

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

Interpersonal variables Signup and view all the answers

What is essential for effective communication in a physical environment?

Physical and emotional comfort and safety Signup and view all the answers

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

Intonation Signup and view all the answers

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

Motivational interviewing Signup and view all the answers

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

Nurse-family relationships Signup and view all the answers

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

SBAR technique Signup and view all the answers

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

Lateral violence Signup and view all the answers

What is the meaning of connotative?

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

What is the primary purpose of therapeutic communication techniques?

To encourage the expression of feelings and ideas and convey acceptance and respect Signup and view all the answers

What is the opposite of therapeutic communication techniques?

Nontherapeutic communication techniques Signup and view all the answers

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

Culture and language Signup and view all the answers

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

Through the patient's eyes Signup and view all the answers

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

The plan of care is modified Signup and view all the answers

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

To improve patient outcomes Signup and view all the answers

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

To improve patient outcomes Signup and view all the answers

What is an important aspect of patient-centered communication?

Focusing on patient needs and concerns 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.