Nursing Informatics Chapter 26

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Questions and Answers

What is the primary purpose of documentation in healthcare?

  • To facilitate reimbursement and billing
  • To facilitate interprofessional communication (correct)
  • To provide a legal record of care
  • To track a patient's clinical course

What is the term for a system that stores an individual's lifetime computerized health record?

  • Health Information Technology for Economic and Clinical Health (HITECH)
  • Electronic Health Record (EHR) (correct)
  • Electronic Medical Record (EMR)
  • Electronic Health Record System (EHRS)

What is the main advantage of using electronic documentation?

  • It increases the security and confidentiality of patient records (correct)
  • It shifts the focus from reimbursement to quality improvement
  • It reduces the need for interprofessional communication
  • It reduces the need for auditing and monitoring

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

<p>To protect patients' protected health information (PHI) (A)</p> Signup and view all the answers

What is the term for the process of determining hours of care and number of staff required for a group of patients?

<p>Acuity rating system (D)</p> Signup and view all the answers

What is the primary purpose of using flow sheets in documentation?

<p>To organize patient assessment data (C)</p> Signup and view all the answers

What is the term for a report that documents unusual events or incidents?

<p>Incidence or occurrence report (A)</p> Signup and view all the answers

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

<p>To ensure accuracy and clarity of communication (A)</p> Signup and view all the answers

What is the term for the guidelines that ensure quality documentation?

<p>Standards and Guidelines for Quality Nursing Documentation (C)</p> Signup and view all the answers

What is the primary purpose of using charting by exception?

<p>To reduce documentation time and increase efficiency (D)</p> Signup and view all the answers

What is the primary factor in determining a patient's acuity level?

<p>The type and number of nursing interventions required over a 24-hour period (D)</p> Signup and view all the answers

What organization is responsible for regulating documentation in the long-term health care setting?

<p>The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) (B)</p> Signup and view all the answers

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

<p>To justify reimbursement from Medicare, Medicaid, or private insurance companies (A)</p> Signup and view all the answers

What is the Omaha system used for in the home health care setting?

<p>To document clinical assessments and care provided (A)</p> Signup and view all the answers

What is the primary goal of the case management model?

<p>To incorporate an interprofessional approach to delivery and documentation of patient care (D)</p> Signup and view all the answers

What is a critical pathway?

<p>An interprofessional care plan that identifies patient problems, key interventions, and expected outcomes within an established time frame (C)</p> Signup and view all the answers

What is a variance in the context of critical pathways?

<p>An unexpected outcome, unmet goal, or intervention not specified within a critical pathway (B)</p> Signup and view all the answers

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

<p>To enhance the quality and efficiency of care (A)</p> Signup and view all the answers

What is a nursing clinical information system (NCIS)?

<p>A system that uses nursing models and critical pathways to document patient care (B)</p> Signup and view all the answers

What is the primary focus of nursing informatics?

<p>The integration of nursing science, computer science, and information science (C)</p> Signup and view all the answers

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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 (diagnosis-related groups)
  • Auditing and monitoring
  • Education
  • Research

Electronic Documentation

  • Shift to electronic documentation (electronic health record system (EHRS))
  • Electronic health record (EHR): an individual's lifetime computerized record
  • Electronic medical record (EMR): the record for an individual health care visit

Privacy, Confidentiality, and Security

  • Maintaining privacy, confidentiality, and security of the health care record
  • Protected health information (PHI)
  • Privacy, confidentiality, and security mechanisms (firewall, password)
  • Handling and disposing of information (procedures for nursing students, 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

  • Documentation of patient assessment data
  • 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

  • Acuity rating system: used to determine hours of care and number of staff required for a group of patients every shift or every 24 hours
  • Patient's acuity level: based on the type and number of nursing interventions required by that patient 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 to establish eligibility for home care reimbursement
  • Documentation is the quality control and the justification for reimbursement from Medicare, Medicaid, or private insurance companies
  • Nurses use two different data sets to document clinical assessments and care provided in the home care setting (OASIS, Omaha system)

Case Management and Use of Critical Pathways

  • Case management model: incorporates an interprofessional approach to delivery and documentation of patient care
  • Critical pathways: interprofessional care plans that identify 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): used to enhance quality and efficiency of care
  • Health care information system (HIS): 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, clinical database development

Clinical Decision Support Systems (CDSS)

  • Aids and supports clinical decision making

Nursing Informatics

  • Specialty area of practice
  • Integrates nursing science, computer science, and information science
  • Informatics competencies for nursing graduates

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