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What is the primary goal of a Clinical Decision Support System (CDSS)?
What is the main advantage of using a critical pathway design in a Nursing Clinical Information System (NCIS)?
What is the primary focus of a nursing model design in a Nursing Clinical Information System (NCIS)?
What is the main function of the knowledge base within a Clinical Decision Support System (CDSS)?
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What is the primary focus of nursing informatics?
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What is the main advantage of using a Nursing Clinical Information System (NCIS)?
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What is the primary goal of informatics competencies for nursing graduates?
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How many designs are typically used in a Nursing Clinical Information System (NCIS)?
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What is the primary focus of the principle of beneficence in healthcare?
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What is the term for the branch of ethics that focuses on healthcare?
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What is the primary goal of values clarification in ethical decision-making?
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What is the term for a deeply held personal belief about the worth of an idea, custom, or object?
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What is the primary focus of the principle of autonomy in healthcare?
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What is the term for a set of guiding principles that all members of a profession accept?
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What is the term for a situation where two opposing courses of action can both be justified by ethical principles?
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What is the primary focus of the principle of nonmaleficence in healthcare?
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What is the primary purpose of an acuity rating system?
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What is the basis of a patient's acuity level?
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What is the range of a patient's acuity level classification?
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What governs documentation in the Long-Term Health Care Setting?
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What is the primary goal of health care information technology (HIT)?
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What are the two types of health care information systems?
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What is an example of a clinical information system (CIS)?
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What is the function of computerized provider order entry (CPOE)?
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What is moral distress?
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What is the purpose of an ethics committee?
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What is the first step in processing an ethical problem?
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What is the focus of deontology in ethics?
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What is the primary focus of utilitarianism?
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What is the focus of feminist ethics?
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What is the focus of ethics of care?
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What is a common source of ethical problems in healthcare?
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What is the main purpose of documenting patient assessment data?
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What is the philosophy behind charting by exception?
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What is the purpose of a discharge summary form?
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How should the abbreviation 'unit' be written in nursing documentation?
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What is the purpose of a care plan?
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What is the main characteristic of a flow sheet in nursing documentation?
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What should be included in a patient care summary?
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What is the purpose of progress notes in nursing documentation?
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Study Notes
Standards and Guidelines for Quality Nursing Documentation
- Record entries and reports should be organized, concise, clear, and complete, containing essential information.
- Use standardized abbreviations, such as "unit" instead of "unit of measurement", and avoid using decimal points after whole numbers.
Methods of Documentation
- Documentation of patient assessment data includes:
- Flow sheets, which are organized by body systems and navigated using a computer mouse.
- Progress notes, which monitor and record patient progress toward resolving problems.
- Charting by exception, which assumes that all standards for normal assessment findings or routine care activities are met unless otherwise documented.
Common Record-Keeping Forms within the Electronic Health Record
- Includes:
- Admission nursing history form
- Patient care summary
- Care plans
- Discharge summary forms
Acuity Rating Systems
- Used to determine hours of care and number of staff required for a group of patients every shift or every 24 hours.
- Patient acuity level is based on the type and number of nursing interventions required by the patient over a 24-hour period.
Documentation in the Long-Term Health Care Setting
- Governed by individual state regulations, The Joint Commission, and Centers for Medicare and Medicaid Services (CMS).
- Notes: Check for pain management.
Informatics and Information Management in Health Care
- Health care information technology (HIT) enhances quality and efficiency of care by recording, monitoring, and delivering patient care.
- Health care information system (HIS) consists of two types:
- Clinical information system (CIS)
- Administrative information system
- Examples of CIS:
- Computerized provider order entry (CPOE)
- Nursing clinical information systems (NCIS)
- NCIS designs:
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- Nursing model
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- Critical pathway
-
- Advantages of NCIS:
- Better information access
- Better documentation quality
- Reduced errors of omission
- Reduced hospital costs
- Increased nurse job satisfaction
- Clinical database development
Clinical Decision Support Systems (CDSS)
- Aids and supports clinical decision making by providing tailored recommendations for individual patients.
Nursing Informatics
- Specialty area of practice that integrates nursing science, computer science, and information science.
- Informatics competencies for nursing graduates require knowledge of nursing informatics science and application.
Ethics and Values
Basic Terms in Health Ethics
- Morals: Judgment or behavior based on beliefs
- Value: A deeply held personal belief about the worth of an idea, custom, object
- Bioethics: Branch of ethics in healthcare
- Autonomy: Freedom of external control
- Beneficence: A positive action to help others
- Nonmaleficence: Avoidance of harm or hurt
- Justice: Fairness and distribution of resources
- Fidelity: Faithfulness and keeping promises
Professional Nursing Code of Ethics
- Code of ethics: Set of guiding principles that all members of a profession accept
- Key principles:
- Advocacy
- Responsibility
- Accountability
- Confidentiality
Values
- Value clarification: Resolving ethical conflicts by distinguishing among value, fact, and opinion
- Clarifying values: Important for effective ethical discourse
Nursing Point of View
- Types of ethical problems:
- Ethical dilemma
- Moral distress
- Ethics committees
- Processing an ethical problem:
- Step 1: Ask if it's an ethical problem
- Step 2: Gather relevant information
- Step 3: Identify ethical elements and examine values
- Step 4: Name the problem
- Step 5: Identify possible courses of action
- Step 6: Create and implement an action plan
- Step 7: Evaluate the action plan
Issues in Health Care Ethics
- Social media: Can be a supportive source of information about patient care or professional nursing activities
- Quality of life: Deeply personal
- Care at the end of life: Frequent source of ethical problems
- Access to health care: Not always available
Approaches to Ethics
- Deontology: Defines actions as right or wrong based on adherence to rules and principles
- Utilitarianism: Focuses on the greatest good for the greatest number of people
- Casuistry: Case-based reasoning, focusing on the details of a situation
- Feminist ethics: Natural caring for others is the basis for moral behavior, focusing on practical situations and relationships
- Ethics of care: Focuses on understanding relationships, personal narratives, and context in which ethical problems arise.
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Description
This quiz covers the basics of nursing practice, including vital signs, pain assessment, and administration of medications and treatments. It also reviews proper recording and reporting techniques.