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?

To protect patients' protected health information (PHI) 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?

Acuity rating system Signup and view all the answers

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

To organize patient assessment data Signup and view all the answers

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

Incidence or occurrence report Signup and view all the answers

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

To ensure accuracy and clarity of communication Signup and view all the answers

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

Standards and Guidelines for Quality Nursing Documentation Signup and view all the answers

What is the primary purpose of using charting by exception?

To reduce documentation time and increase efficiency Signup and view all the answers

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

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

What organization is responsible for regulating 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 justify reimbursement from Medicare, Medicaid, or private insurance companies Signup and view all the answers

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

To document clinical assessments and care provided Signup and view all the answers

What is the primary goal of the case management model?

To incorporate an interprofessional approach to delivery and documentation of patient care Signup and view all the answers

What is a critical pathway?

An interprofessional care plan that identifies patient problems, key interventions, and expected outcomes within an established time frame Signup and view all the answers

What is a variance in the context of critical pathways?

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

What is a nursing clinical information system (NCIS)?

A system that uses nursing models and critical pathways to document patient care Signup and view all the answers

What is the primary focus of nursing informatics?

The integration of nursing science, computer science, and information science 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 (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