Nursing Documentation and Technology

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Questions and Answers

What is the primary purpose of using computer-generated client documentation in nursing?

To evaluate the effectiveness of hospital services

To facilitate automated staff scheduling

To reduce the cost of nursing services

To enhance the quality of patient care through accurate and efficient documentation (correct)

What is one of the benefits of using electronic medical records (EMRs) and computer-based patient records (CPRs)?

Direct monitoring of vital signs and other measurements

Improved patient satisfaction

Enhanced data analysis for research (correct)

Automated billing for supplies and procedures

How can computers be used in nursing diagnosis?

To evaluate the effectiveness of treatment

To develop a care plan for the patient

To generate a list of possible diagnoses for a patient with certain signs and symptoms (correct)

To retrieve and review patient records according to the nursing diagnosis

What is one of the uses of informatics in nursing planning?

To display recommended interventions for selected diagnoses and expected outcomes Signup and view all the answers

How can computers be used in nursing implementation?

To record interventions and patient information Signup and view all the answers

What is one of the uses of informatics in nursing evaluation?

To compare large amounts of patient data to identify outcomes Signup and view all the answers

What is one of the roles of nurse administrators in using informatics?

To define the cost of nursing services Signup and view all the answers

What is one of the primary ways that informatics has changed nursing practice?

Through documentation Signup and view all the answers

What is one of the benefits of using informatics in nursing administration?

Facilitation of nursing processes Signup and view all the answers

In what area of nursing practice can informatics be applied to define the cost of nursing services?

Administration Signup and view all the answers

What is an example of an application of Nursing Informatics in nursing practice for nurses?

Work lists to remind staff of planned nursing interventions Signup and view all the answers

In what area of nursing practice can informatics be applied to develop computer-assisted instruction?

Education Signup and view all the answers

What is a benefit of using informatics in nursing practice?

Improving care coordination Signup and view all the answers

In what area of nursing practice can informatics be applied to monitor patient data?

Clinical Practice Signup and view all the answers

What is an application of Nursing Informatics in nursing research?

Data gathering Signup and view all the answers

What is another term used to describe Health Informatics?

Health Informatics Signup and view all the answers

What is a use of informatics in nursing education?

Interactive video technology Signup and view all the answers

What is a benefit of using informatics in nursing research?

To find trends in aggregate data Signup and view all the answers

What is an example of a clinical alert system?

A system that alerts pharmacy and health staff to incompatible drug prescriptions Signup and view all the answers

How can informatics be used in a physician's clinic?

To manage every aspect of patient care Signup and view all the answers

What is tele-health?

The use of digital information and communication technologies to access health care services Signup and view all the answers

What is an example of a use of informatics in patient education?

Teaching patients effective symptom management Signup and view all the answers

What is a use of informatics in cost analysis?

To analyze cost trends for budget purposes Signup and view all the answers

What is a use of informatics in nursing research?

To use Statistical Package of Social Sciences (SPSS) Signup and view all the answers

Study Notes

Computer-Generated Client Documentation

Electronic Medical Record (EMR) and Computer-Based Patient Record (CPR) enhance documentation by nurses.
Monitoring devices record vital signs and measurements directly into the client record (EMR).

Nursing Care Plans and Critical Pathways

Computer-generated nursing care plans and critical pathways facilitate care planning.
Automatic billing for supplies or procedures is linked to nursing documentation.
Reminders and prompts ensure comprehensive charting.

Data Analysis and Research

Provision of data enables research on relationships between data elements and nursing outcomes.
Identifying optimal nursing care is facilitated through data analysis.

Clinical Implementation

Computers are used in:
- Assessment
- Patient Monitoring
- Documentation
- Telemedicine

Uses of Informatics in Nursing

Diagnosis

Computers generate lists of possible diagnoses for patients with specific signs and symptoms.
Retrieval and review of patient records according to nursing diagnosis is facilitated.

Planning

Computer programs display recommended interventions for selected diagnoses and expected outcomes.

Implementation

Computers record interventions and patient information, communicating with other departments.

Evaluation

Computers compare large amounts of patient data to identify outcomes.
Information from other healthcare members is used to determine future actions and discharge planning.

Uses of Informatics in Nursing Administration

Informatics is used to:
- Define the cost of nursing services
- Evaluate quality assurance and outcomes analysis
- Demonstrate cost effectiveness and find trends for budget purposes
- Facilitate nursing processes
- Justify roles of each hospital employee
- Automate staff scheduling

Applications of Nursing Informatics

Nursing Informatics can be applied to:
- Clinical Practice
- Administration
- Education
- Research
- Patients Education
- Clinical Alert System
- Patient Data
- Tele-health

Introduction

Informatics has changed nursing practice through documentation and care coordination.
Tracking staffing, workflow, and communication can improve nursing processes.

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Description

This quiz covers the use of technology in nursing documentation, including electronic medical records, computer-based patient records, and computer-generated care plans and critical pathways.