Informatics and Documentation in Healthcare

Questions and Answers

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

Therapeutic communication (correct)

Intrapersonal communication

Verbal communication

Interpersonal communication

What is the equation for Clinical judgment?

Observed outcome of critical thinking + decision making

Circular transactional model of communication includes the referent, sender, and receiver.

True

Denotative meaning is the same for everyone who speaks English, while connotative meaning is influenced by the _________ people have about the word.

thoughts, feelings, or ideas Signup and view all the answers

What is the main purpose of documentation in healthcare?

All of the above Signup and view all the answers

Match the following components of Verbal communication with their descriptions:

Pacing = Speaking moderately slowly and enunciating clearly Intonation = Tone of voice dramatically affecting the meaning of a message Clarity and Brevity = Keeping communication simple, brief, and direct Timing and relevance = Ensuring effective communication by updating patients at appropriate times Signup and view all the answers

What is the difference between an Electronic Health Record (EHR) and an Electronic Medical Record (EMR)?

EHR contains an individual's lifetime computerized record, while EMR is for an individual health care visit. Signup and view all the answers

HIPAA violations can occur if a healthcare provider fails to log out or turn off their screen when dealing with Protected Health Information (PHI).

True Signup and view all the answers

Documentation by exception (CBE) ensures that all standards for normal assessment findings are met unless otherwise __________.

documented Signup and view all the answers

Match the following terms in Health Ethics with their definitions:

Autonomy = Acknowledging and protecting a patient's independence Beneficence = Acting in the patient's best interests over self-interest Nonmaleficence = Commitment to do no harm Justice = Fairness and resource distribution Fidelity = Faithfulness and promise-keeping Signup and view all the answers

What is the primary purpose of documentation in healthcare?

To provide a written account of patient data and clinical interventions Signup and view all the answers

What is the main benefit of interprofessional communication within the medical record?

Facilitated interprofessional communication Signup and view all the answers

What is the term for a computerized record of an individual's lifetime health information?

Electronic Health Record (EHR) Signup and view all the answers

What is the purpose of the Health Information Technology for Economic and Clinical Health Act (HITECH)?

To promote the adoption of electronic health records Signup and view all the answers

What is the term for the information that healthcare providers are legally required to protect?

Protected Health Information (PHI) Signup and view all the answers

What is the purpose of maintaining privacy, confidentiality, and security mechanisms in healthcare records?

To prevent HIPAA violations Signup and view all the answers

What type of notes do healthcare providers write within the EHR?

Narrative progress notes Signup and view all the answers

What is the purpose of charting by exception (CBE)?

To ensure that all standards for normal assessment findings are met unless otherwise documented Signup and view all the answers

What is the primary purpose of health care information technology (HIT)?

To enhance quality and efficiency of care Signup and view all the answers

What is the primary focus of the utilitarianism approach to ethics?

Achieving the greatest good Signup and view all the answers

What is an example of a clinical information system (CIS)?

Computerized provider order entry (CPOE) Signup and view all the answers

Which approach to ethics emphasizes the importance of caring relationships and personal responsibility?

Ethics of care Signup and view all the answers

What type of documentation format incorporates data, action, and response (DAR)?

Focus charting Signup and view all the answers

What is the purpose of computerized provider order entry (CPOE)?

To allow healthcare providers to input orders electronically Signup and view all the answers

What is the term for being forced to take a specific action that goes against one's moral beliefs?

Moral distress Signup and view all the answers

What is the term for distinguishing among value, fact, and opinion to resolve ethical conflicts?

Distinguishing among value, fact, and opinion Signup and view all the answers

What is the main purpose of the Admission nursing history form?

To document patient admission information Signup and view all the answers

What is the key element in deontological ethics?

Following rules and principles Signup and view all the answers

What is the difference between a health care information system (HIS) and a clinical information system (CIS)?

A HIS is used for administrative tasks, while a CIS is used for clinical tasks Signup and view all the answers

What organization audits hospitals and charts for documentation compliance?

All of the above Signup and view all the answers

What is the term for lying, even if it's a white lie?

Ethical dilemma Signup and view all the answers

What is the primary goal of patient education?

To help individuals, families, or communities achieve optimal levels of health. Signup and view all the answers

What type of documentation format identifies nursing problems or diagnoses?

PIE notes Signup and view all the answers

What is the primary focus of feminist ethics?

Natural caring for others Signup and view all the answers

What is the purpose of an ethics committee in a healthcare setting?

To resolve ethical dilemmas and teach ethical principles Signup and view all the answers

What is the purpose of the 'teach-back' method in effective communication?

To evaluate the success of a teaching plan by gaining feedback from the receiver. Signup and view all the answers

What are the three domains of learning that are most effective when used together?

Cognitive, affective, and psychomotor learning. Signup and view all the answers

What is the purpose of the ACCESS model in patient education?

To focus on cultural factors that influence patient education outcomes. Signup and view all the answers

What is the first step in processing an ethical problem?

Ask Signup and view all the answers

What is the purpose of the 'evaluate the plan' step in processing an ethical problem?

To assess the effectiveness of the plan. Signup and view all the answers

What is the primary focus of maintenance and promotion of health in patient education?

Adopting healthier behaviors. Signup and view all the answers

What is the purpose of the 'name problem' step in processing an ethical problem?

To clearly define the problem. Signup and view all the answers

What is the primary goal of the nursing team in managing patient care?

To work together to achieve the best outcomes for patients Signup and view all the answers

What is a characteristic of a Magnet hospital?

A focus on research and evidence-based practice Signup and view all the answers

What is the role of the RN in managing patient care?

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

What is the primary purpose of case management?

To coordinate healthcare services across all levels of care Signup and view all the answers

What is the term for the decision-making approach used in healthcare organizations?

Shared governance Signup and view all the answers

What is the term for the duties and activities that a healthcare professional is employed to perform?

Responsibility Signup and view all the answers

What is the primary 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 term for the process of coordinating healthcare services across all levels of care?

Case management 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 healthcare record serves multiple purposes, including facilitating interprofessional communication, providing a legal record of care, justifying financial billing and reimbursement, supporting quality and performance improvement, and serving as a resource for education and research.
Interprofessional communication within the medical record includes legal documentation, reimbursement, auditing and monitoring, education, and research.

Electronic Health Records

An Electronic Health Record (EHR) is an individual's lifetime computerized record.
An Electronic Medical Record (EMR) is the record for an individual healthcare visit.
The American Recovery and Reinvestment Act (ARRA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) promote the adoption and meaningful use of EHRs.

Maintaining Privacy, Confidentiality, and Security

Protected Health Information (PHI) must be protected by logging out or turning off screens and adhering to HIPAA guidelines.
Mechanisms to ensure privacy, confidentiality, and security include firewalls and passwords.

Guidelines for Quality Documentation

Guidelines for quality documentation include flow sheets, progress notes, and charting by exception (CBE).
Healthcare providers write narrative progress notes in various formats, such as focus charting, SOAP notes, and notes with a specific nursing focus.

Common Record-Keeping Forms

Common record-keeping forms within the Electronic Health Record (EHR) include admission nursing history forms, patient care summaries, care plans, and discharge summary forms.

Governance and Regulation

Documentation is governed by individual state regulations, The Joint Commission (TJC), and the Centers for Medicare and Medicaid Services (CMS).

Health Care Information Technology

Health care information technology (HIT) is used to enhance the quality and efficiency of care.
Health care information systems (HIS) include clinical information systems and administrative information systems.
Clinical information systems (CIS) include computerized provider order entry (CPOE) and nursing clinical information systems (NCIS).

Ethics

Ethics is the study of right and wrong behavior.
Basic terms in health ethics include morals, values, bioethics, autonomy, beneficence, nonmaleficence, justice, and fidelity.
The Code of Ethics for Nursing includes advocacy, responsibility, accountability, confidentiality, and fidelity.

Approaches to Ethics

Approaches to ethics include deontology, utilitarianism, casuistry, feminist ethics, and ethics of care.
Ethical problems include ethical dilemmas and moral distress.
Ethics committees process and teach ethical issues and dilemmas.

Patient Education

Patient education aims to help individuals, families, or communities achieve optimal levels of health.
The goal of patient education is to promote health, prevent illness, and cope with impaired function.
Effective communication involves feedback from the sender and receiver, and the educator delivers instruction and evaluates the success of the teaching plan.

Managing Patient Care

A nursing team works together to achieve the best outcomes for patients.
Effective team development requires team building and training, trust, communication, and a workplace that facilitates collaboration.
A Magnet hospital has a transformed culture with a practice environment that supports professional autonomy and empowerment.

Critical Thinking and Clinical Judgment

Clinical judgment is the observed outcome of critical thinking and decision-making.
Clinical decision-making involves identifying patient needs, setting priorities, and taking action.
Reflection is a process of reviewing a situation to learn from it.

Communication

Competent communication maintains effective relationships within the entire sphere of professional practice.
Therapeutic communication occurs within a healing relationship between a nurse and patient.
Nurses who develop critical thinking skills and clinical judgment make the best communicators.
The circular transactional model of communication includes the referent, sender and receiver, message, channels, context or environment, feedback, and interpersonal variables.

Barriers to Communication

Barriers to communication include perceptual biases or stereotypes, noise, distractions, and lack of privacy or space.
Verbal communication involves vocabulary, denotative and connotative meaning, pacing, intonation, clarity, and brevity.

Therapeutic 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 or behaviors in others.

Nurse-Family Relationships

Nurse-family relationships require forming caring relationships with entire families in community and home care settings.

Nurse-Health Care Team Relationships

Effective communication with other members of the health care team affects patient outcomes, patient safety, and the work environment.
Lateral violence, or bullying between colleagues, can occur and includes behaviors such as withholding information and criticizing without solutions.

Informatics and Documentation

Documentation is a key communication strategy in healthcare that produces a written account of patient data, clinical interventions, and patient responses.
It is available to all members of the healthcare team and allows others to track a patient's clinical course.
Purposes of healthcare records include facilitating interprofessional communication, providing a legal record of care, justifying financial billing and reimbursement, supporting quality and performance improvement, and serving as a resource for education and research.
An electronic health record (EHR) is an individual's lifetime computerized record, whereas an electronic medical record (EMR) is a record for an individual healthcare visit.

Maintaining Privacy and Security

Protected health information (PHI) must be maintained to ensure privacy, confidentiality, and security of the healthcare record.
Mechanisms to maintain privacy and security include firewalls and passwords.
Guidelines for quality documentation include maintaining patient assessment data, using flow sheets, progress notes, and charting by exception (CBE).

Record-Keeping Forms

Common record-keeping forms within an EHR include admission nursing history forms, patient care summaries, care plans, and discharge summary forms.
Documentation is governed by individual state regulations, The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS).

Healthcare Information Technology

Healthcare information technology (HIT) enhances quality and efficiency of care.
A healthcare information system (HIS) has two types: clinical information system (CIS) and administrative information system.
A CIS example is computerized provider order entry (CPOE), which promotes accountability and confidentiality.

Ethics in Healthcare

Approaches to ethics include deontology, utilitarianism, casuistry, feminist ethics, and ethics of care.
Ethical problems may arise, including ethical dilemmas and moral distress.
Ethics committees are devoted to teaching and processing ethical issues and dilemmas.
Processing an ethical problem involves a 7-step approach: ask, gather, identify the problem, name the problem, explore possible actions, take action, and evaluate the plan.

Patient Education

The goal of patient education is to help individuals, families, or communities achieve optimal levels of health.
Effective communication involves feedback from the sender and receiver.
The most effective learning takes place when all three domains of learning are used: cognitive, affective, and psychomotor.
ACCESS helps focus on cultural factors that influence patient education outcomes.

Managing Patient Care

A strong nursing team works together to achieve the best outcomes for patients.
Effective team development requires team building and training, trust, communication, and a workplace that facilitates collaboration.
Magnet-certified hospitals have a transformed culture with a practice environment that is supportive of nurses' professional autonomy.
The Institute for Patient-and Family-Centered Care identified four core concepts for patient-centered care.
Case management coordinates and links healthcare services across all levels of care for patients and their families while streamlining costs and maintaining quality.

Decision Making

Shared governance is a decentralized structure used within healthcare organizations, allowing decisions to be made at the staff level.
Decision making involves responsibility and accountability for duties and activities performed.

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Description

This quiz covers the importance of documentation in healthcare, including its purposes such as facilitating communication and providing a legal record of care.