Nursing Informatics and Documentation

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Questions and Answers

What is the primary purpose of documentation in healthcare?

To provide a legal record of care

To justify financial billing and reimbursement of care

To track a patient's clinical course

To facilitate interprofessional communication (correct)

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

To standardize medical records across healthcare settings

To implement electronic health record systems (correct)

To reduce healthcare costs

To ensure patient privacy and confidentiality

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

EHRs are lifetime records, while EMRs are visit-specific records (correct)

EHRs are used for inpatient care, while EMRs are used for outpatient care

EHRs are individualized, while EMRs are standardized

EHRs are used by physicians, while EMRs are used by nurses

What is the primary concern when maintaining electronic health records?

Data privacy and security Signup and view all the answers

What is the purpose of an acuity rating system?

To determine hours of care and staff required Signup and view all the answers

What type of documentation is used to record patient assessment data?

Flow sheets Signup and view all the answers

What is the primary purpose of documenting telephone calls and verbal orders?

To maintain a record of provider communication Signup and view all the answers

What is the purpose of the Admission Nursing History Form?

To provide a comprehensive overview of patient history and needs Signup and view all the answers

What is the primary goal of quality nursing documentation?

To facilitate interprofessional communication Signup and view all the answers

What is a key principle of quality nursing documentation?

All of the above Signup and view all the answers

What is patient's acuity level based on?

The type and number of nursing interventions required by that patient over a 24-hour period Signup and view all the answers

Which organization governs documentation in the long-term health care setting?

The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) Signup and view all the answers

What is the primary purpose of documentation in the home health care setting?

To establish eligibility for home care reimbursement Signup and view all the answers

What is a critical pathway?

A care plan that outlines patient problems and interventions Signup and view all the answers

What is a variance in case management?

An unexpected outcome, unmet goal, or intervention not specified within a critical pathway 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 a clinical information system (CIS)?

A type of health care information system (HIS) Signup and view all the answers

What is the primary advantage of nursing clinical information systems (NCIS)?

Better information access Signup and view all the answers

What is nursing informatics?

A specialty area of practice that integrates nursing science, computer science, and information science Signup and view all the answers

What is OASIS?

A data set used to document clinical assessments and care provided in the home care setting Signup and view all the answers

Study Notes

Documentation

Documentation is a key communication strategy 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 the Health Care Record

Facilitates interprofessional communication
Provides a legal record of care
Provides justification for financial billing and reimbursement of care
Supports the process of quality and performance improvement
Serves as a resource for education and research

Interprofessional Communication Within the Medical Record

Legal documentation
Reimbursement (e.g., diagnosis-related groups)
Auditing and monitoring
Education
Research

Electronic Documentation

Shift to electronic health record systems (EHRS)
Electronic health record (EHR): an individual's lifetime computerized record
Electronic medical record (EMR): the record for an individual healthcare visit

Maintaining Privacy, Confidentiality, and Security

Protected health information (PHI)
Mechanisms to ensure privacy, confidentiality, and security (e.g., firewall, password)
Procedures for handling and disposing of information
Policies for the use of fax machines

Standards and Guidelines for Quality Nursing Documentation

Factual
Accurate
Appropriate use of abbreviations
Current
Organized
Complete

Methods of Documentation

Flow sheets
Progress notes
Charting by exception

Common Record-Keeping Forms within the Electronic Health Record

Admission nursing history form
Patient care summary
Care plans
Discharge summary forms

Documenting Communication with Providers and Unique Events

Telephone calls
Telephone and verbal orders
Incidence or occurrence reports

Acuity Rating Systems

Used to determine hours of care and number of staff required for a group of patients
Patient's acuity level based on the type and number of nursing interventions required over a 24-hour period

Documentation in the Long-Term Health Care Setting

Governed by individual state regulations, The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS)

Documentation in the Home Health Care Setting

Medicare has specific guidelines for home care reimbursement
Documentation is quality control and justification for reimbursement from Medicare, Medicaid, or private insurance companies
Uses two data sets: OASIS and Omaha system

Case Management and Use of Critical Pathways

Case management model incorporating an interprofessional approach to delivery and documentation of patient care
Critical pathways: interprofessional care plans identifying patient problems, key interventions, and expected outcomes within an established time frame
Variances: unexpected outcomes, unmet goals, and interventions not specified within a critical pathway

Informatics and Information Management in Health Care

Health care information technology (HIT) enhances quality and efficiency of care
Health care information system (HIS) has two types: clinical information system and administrative information system
Clinical information system (CIS) example: computerized provider order entry (CPOE)

Nursing Clinical Information Systems (NCIS)

Two designs: nursing model and critical pathway
Advantages: better information access, better documentation quality, reduced errors of omission, reduced hospital costs, increased nurse job satisfaction, and clinical database development

Clinical Decision Support Systems (CDSS)

Aids and supports clinical decision making