Clinical Nursing Documentation Best Practices
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Questions and Answers

What is one of the characteristics of Electronic Clinical Nursing Documentation?

  • Enhance the quality of clinical care only
  • Provide irrelevant information to healthcare professionals
  • Eliminate redundancies and duplication in documentation
  • Automate an ideal clinical documentation workflow (correct)

    • A Hospital Information System is only used for managing patient records.

    False

    What is the purpose of database servers in a Hospital Information System?

    To store information on medicines required to cure relevant sicknesses

    One of the operational requirements of a Hospital Information System is to provide _____________ information.

    <p>up-to-date factual</p> Signup and view all the answers

    Match the following system requirements with their descriptions:

    <p>Operational = Provide up-to-date factual information Planning = Make short and long-term decisions about patient care Documentation = Maintain records and ensure accreditation</p> Signup and view all the answers

    What is one of the hardware requirements of a Hospital Information System?

    <p>Computer system</p> Signup and view all the answers

    Electronic Clinical Nursing Documentation only enhances the quality of clinical care, but does not provide useful information to healthcare professionals.

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

    What is one of the benefits of using a Hospital Information System that consumes the facilities of the World Wide Web?

    <p>It can be constantly updated for any necessary changes</p> Signup and view all the answers

    What is the primary objective of a Hospital Information System (HIS)?

    <p>To manage patient data and information in a centralized way</p> Signup and view all the answers

    A Hospital Information System (HIS) can prevent medical errors caused by doctor handwriting.

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

    What is one of the disadvantages of paper-based systems in hospitals?

    <p>Paper-based systems can be destroyed by fire and water, and can be misplaced by staff.</p> Signup and view all the answers

    A Hospital Information System (HIS) provides a computer-based framework to facilitate the communication of information within a ________________ setting.

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

    What is one of the advantages of a Hospital Information System (HIS)?

    <p>Reducing medical costs</p> Signup and view all the answers

    Match the following features with their corresponding functions in a Hospital Information System (HIS):

    <p>Appointments = Make appointments with doctors Online Payments = Conduct payments online Live Conversations = Perform live conversations with doctors regarding health topics Staff and Customer Accounts = Manage staff and customer accounts within the information system</p> Signup and view all the answers

    A Hospital Information System (HIS) can reduce the need for retesting.

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

    What type of records are collected and stored electronically in a Hospital Information System (HIS)?

    <p>Patient health information, test results, doctor and specialist visits, and healthcare treatments.</p> Signup and view all the answers

    Which of the following stakeholders is supported by the Electronic Health Record (EHR)?

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

    A common, clinically rich vocabulary is a requirement for EHR.

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

    What is the purpose of a data model in EHR?

    <p>To describe the medical concepts that can be recorded in the electronic patient file and handled by the patient record system.</p> Signup and view all the answers

    The Electronic Clinical Nursing Documentation includes written evidence of all nursing activities, including ______________________.

    <p>interactions among health care team members</p> Signup and view all the answers

    What is the purpose of an interpreter in EHR?

    <p>To provide analysis, presentation, and communication of patient data</p> Signup and view all the answers

    Match the following characteristics of Electronic Clinical Nursing Documentation with their descriptions:

    <p>Standardization of clinical data and content = A characteristic of Electronic Clinical Nursing Documentation Evaluation of patient outcomes = A part of the plan of care Administration of assessments = A nursing activity included in Electronic Clinical Nursing Documentation</p> Signup and view all the answers

    EHR requires standardized protocols for communication.

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

    What is the purpose of presentation types in EHR?

    <p>To allow the manipulation, presentation, and communication of medical items that are controlled by a large number of parameters.</p> Signup and view all the answers

    Study Notes

    Data Gathering and Recording

    • Data gathering and recording are essential steps in maintaining accurate patient records.
    • Characteristics of Electronic Clinical Nursing Documentation include enhancing quality, defining standard clinical documentation data, and automating clinical documentation workflow.

    Hospital Information System

    • A hospital information system (HIS) is a computer-based framework that facilitates communication of information within a hospital setting.
    • The purpose of HIS is to manage patient data and information in a centralized way, replacing traditional methods of entering and storing data.
    • Functions of HIS include making appointments, conducting online payments, live conversations with doctors, managing staff and customer accounts, and uploading demo videos on sicknesses and cures.

    System Requirements

    • Operational requirements include up-to-date factual information and necessary day-to-day tasks.
    • Planning requirements include short and long-term decisions about patient care, disaster recovery, and hospital management.
    • Documentation requirements include maintaining records, accreditation, and legal records.
    • Hardware requirements include computer systems, Wi-Fi routers, switches, Ethernet cables, and physical server.
    • Software requirements include database servers, Adobe Photoshop, Flash, and Illustrator.

    Electronic Health Record (EHR)

    • EHR supports patients, physicians, nurses, caregivers, pharmacies, local authorities, and accreditation and quality assurance agencies.
    • Requirements for EHR include a physical network, infrastructure, standards for data interchange, a data model, common clinically rich vocabulary, processes for information gathering, and an appropriate security system.
    • Prerequisites for EHR include a data model, presentation types, and communication protocols.

    Electronic Clinical Nursing Documentation

    • Documentation includes written evidence of all nursing activities, including interactions among healthcare team members, administration of assessments, procedures, treatments, and patient education.
    • Evaluation of patient's outcomes as part of the plan of care is also included in electronic clinical nursing documentation.

    Advantages of Hospital Information System

    • Reduces paper-based work to enter and store medical records.
    • Reduces medical errors caused by inaccuracies and doctor handwriting.
    • Reduces medical costs.
    • Prevents retesting.
    • Reduces medical errors leading to health quality improvements.

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    Description

    This quiz assesses understanding of best practices in clinical nursing documentation, including data gathering, communication, and standardization of clinical documentation practices. It covers the importance of eliminating redundancies, enhancing quality and reporting of clinical care, and automating clinical documentation.

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