Telehealth and Medication Administration

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Questions and Answers

What does the acronym DAR stand for in the context of focused charting?

Data, Action, Response (correct)

Direct, Assessment, Recommendation

Diagnosis, Action, Record

Data, Assessment, Response

Which of the following is NOT included in the objective observation section?

Patient's subjective feelings of discomfort (correct)

Blood pressure of 138/88 mmHg

Lung sounds diminished bilaterally

Heart rate of 88/min

What vital sign measurement indicates a potential concern when the patient shows slight dyspnea while speaking?

Respiration rate of 20/min

Temperature of 99.4° F

Heart rate of 88/min

SpO2 of 93% on room air (correct)

Which statement correctly reflects changes in the patient's respiratory status?

Cough presents with thick, green sputum. Signup and view all the answers

What is the primary focus of focus charting in nursing?

Documenting changes in a client's specific health care problem Signup and view all the answers

What role does telehealth play in healthcare delivery?

It facilitates improved access to healthcare services. Signup and view all the answers

Which of the following is NOT a core competency of telehealth in nursing practice?

Financial management skills. Signup and view all the answers

During which phase of the medication administration process is the medication order entered into the patient's record?

Transcription. Signup and view all the answers

What phase follows the actual administration of medication in the medication administration process?

Monitoring and follow-up. Signup and view all the answers

What is the significance of medication reconciliation in the ambulatory care setting?

It ensures accurate documentation of current medications. Signup and view all the answers

Which of the following aspects are essential in preventing medication errors?

Adherence to the phases of the medication administration process. Signup and view all the answers

How does telehealth contribute to addressing the nursing shortage?

By providing remote access to healthcare services. Signup and view all the answers

What is one of the primary benefits of electronic documentation in health care?

Potential cost savings from reduced paperwork Signup and view all the answers

Which feature is commonly included in Electronic Health Records (EHRs) to ensure data security?

Password protection Signup and view all the answers

During EHR downtime, what is the recommended method for health care providers to ensure documentation occurs?

Switch to paper documentation Signup and view all the answers

What does the PIE model emphasize in its approach to documentation?

Incorporating an ongoing plan of care Signup and view all the answers

What is one challenge associated with the adoption of electronic health records?

Workflow integration issues Signup and view all the answers

Which factor must be considered for the successful implementation of electronic documentation?

User acceptance Signup and view all the answers

What is a common outcome of planned or unexpected EHR downtimes?

Disruption to client care Signup and view all the answers

What challenge does electronic documentation require health care providers to address?

Ensuring client data security and privacy Signup and view all the answers

Which of the following statements accurately describes remote patient monitoring (RPM)?

RPM is a form of telehealth medicine that tracks client information. Signup and view all the answers

What aspect does the PIE model focus on within its documentation approach?

Nursing process Signup and view all the answers

Which of the following best describes the transition to electronic documentation?

Requires addressing several challenges Signup and view all the answers

What type of data can be classified as patient-generated health data (PGHD)?

Client's health history and bodily measurements. Signup and view all the answers

Which of the following devices is typically not classified as part of electronic monitoring devices?

Smartphone camera Signup and view all the answers

How do electronic monitoring devices assist health care providers?

They collect and rapidly transfer client data. Signup and view all the answers

What aspect of health literacy is emphasized by Healthy People 2030?

Organizations play a key role in assisting individuals with understanding health information. Signup and view all the answers

Which of the following is NOT a function of remote patient monitoring devices?

Providing prescriptions for medications. Signup and view all the answers

Which of the following physiological measurements can be monitored using electronic monitoring devices?

Blood glucose levels Signup and view all the answers

What advantage do wearable monitoring devices provide for clients?

They allow for real-time monitoring of various health metrics. Signup and view all the answers

What feature do many RPM devices offer to enhance client engagement in their health care?

Interactive self-care tools and educational resources. Signup and view all the answers

What does organizational health literacy aim to achieve?

Equip organizations to help individuals navigate health-related decisions. Signup and view all the answers

What is one of the significant challenges faced during the transition to electronic health records (EHRs)?

High implementation and maintenance costs Signup and view all the answers

Which of the following is NOT a recommended standard for accurate documentation in electronic health records?

Elaborate descriptions Signup and view all the answers

What aspect of Remote Patient Monitoring (RPM) assists in proactive and personalized patient care?

Wearable biosensors that track vital signs Signup and view all the answers

Which factor contributes to alert fatigue among clinicians using EHRs?

Excessive clinical decision support alerts Signup and view all the answers

What is a potential legal ramification related to incomplete documentation in EHRs?

Use of records as evidence in court Signup and view all the answers

What is a critical component of Remote Patient Monitoring?

Mobile apps for transmitting data securely Signup and view all the answers

Which of the following is a common issue with system interoperability among EHR platforms?

Difficulty in sharing patient information Signup and view all the answers

What is an outcome of excessive time required for data entry in EHR systems?

Decreased interaction with patients Signup and view all the answers

What do healthcare organizations need to consider regarding data privacy when using electronic health records?

Patient confidentiality and security breaches Signup and view all the answers

What role do two-way communications play in RPM?

Facilitating education and feedback for patients Signup and view all the answers

Study Notes

Telehealth

Telecommunication technologies are used to facilitate communication between providers and clients
Methods include social media apps, video conferencing, and other media
Purpose is to assess, diagnose, treat, and prevent diseases
Benefits include increased access to healthcare by eliminating the need for travel

Medication Administration

Medication administration process has five phases:
- Medication Prescribing: Healthcare providers evaluate the patient and prescribe the appropriate medication
- Transcription: Medication order is transcribed accurately into the patient's medical record
- Preparing and Dispensing: Medication is prepared and dispensed by pharmacist or nurse
- Administering: Nurse administers medication by the prescribed route and dosage
- Monitoring and Follow-up: Nurse monitors the patient for desired therapeutic effects and adverse reactions, documenting the outcome
Proper adherence to all phases is crucial for safe and effective medication administration

Medication Reconciliation

Joint Commission (TJC) believes that medication reconciliation is important for patient safety in the ambulatory care setting
Nurses and clients work together to confirm and document all of the client's current medications when they are admitted to the healthcare institution
TJC's 2024 National Patient Safety Goals (NPSG) include NPSG 3: Improve the safety of using medications

Electronic Health Records (EHR)

Proven to have great benefits, but there can be legal ramifications if documentation is incomplete or inaccurate
Components of medical records can be used as evidence in a court of law
Nurses must adhere to the ANA's standards which require documentation to be factual, accurate, complete, timely, organized, and compliant
Nurses need to be aware of state and federal regulations, health care facility policies, and their professional obligations to ensure documentation is accurate
Challenges include:
- High implementation and maintenance costs
- Workflow disruptions and productivity loss during transition from paper records
- System interoperability issues
- User training and resistance to change
- Concerns over data privacy, security breaches, and patient confidentiality
- Alert fatigue
- Potential for documentation errors
- Time required for data entry

Remote Patient Monitoring (RPM)

Involves using digital technologies to collect and transmit patient health data from their home or other location to healthcare providers
Key aspects of RPM include:
- Wearable or implantable biosensors that continuously track vital signs
- Mobile apps and connected devices that allow patients to report symptoms and treatment adherence
- Secure transmission of patient data to their care team
- Analysis of the data by providers to monitor disease progression and adjust treatment plans
- Two-way communication between patients and providers
RPM enables more proactive and personalized care for patients with chronic conditions, reduces hospital admissions, and empowers patients to take an active role in self-management

Electronic Monitoring Devices

RPM is assisted by the use of mobile medical devices, sensors, and technology
Information is collected and transferred through wired or wireless devices
Data includes:
- Heart rhythm
- Vital signs
- Blood oxygen saturation level
- Blood glucose level
Monitors can also detect motion or transmit real-time video
Sensors can be placed in clothes or elastic bands directly attached to a client's body
Devices can be used for real-time monitoring in detecting client falls and assessing gait, activity, and sleep patterns
Some RPM devices include the ability to:
- Link clients to their health records
- Provide educational resources and interactive self-care tools
- Connect the client to their health care provider

Patient-Generated Health Data (PGHD)

RPM devices permit clients to produce PGHD
PGHD includes:
- Client health history
- Bodily measurements
- Symptoms
- Individual behavioral factors
Clients are better able to manage their health and be active participants in their healthcare through RPM

Health Literacy:

Focus of Healthy People 2030
Defines health literacy as:
- Personal health literacy: An individual's ability to understand and use health information
- Organizational health literacy: The extent to which organizations equitably assist people with understanding, finding, and using information and services to make informed health-related decisions

Electronic Documentation

Often used as a means of communication among health care providers
Advantages include:
- Increased legibility
- Technical support compared to handwritten records
- Potential cost savings from reduced paperwork and improved efficiency

Documentation During EHR Downtime

EHRs can experience downtimes
Events can be planned or unexpected
Downtimes can be disruptive to client care
Nurses must be aware of their facility's procedures for managing events
Documentation still needs to occur during downtime
Healthcare providers often switch to paper documentation during downtime

Documentation Methods

Several different systems can be used for documenting client information
The system used depends on the facility
Methods include:
- Charting by exception
- Problem-oriented medical records (POMR)
- Source-oriented records
- Problem, Intervention, Evaluation (PIE)
- Focus charting
- Electronic health records (EHRs)

PIE Model

Simplified approach to documentation that uses flowsheets and progress notes
Focuses on the nursing process and includes an ongoing plan of care
Problem is defined using a nursing diagnosis
Information is collected from the client, caregiver, or family member
Includes three components:
- P: Problem: Nursing diagnosis
- I: Interventions: Nursing actions
- E: Evaluation: Evaluation of efficacy of interventions
The example in the text shows Objective data under "O"

Focus Charting

Focuses on client's specific health care problem by focusing on the nursing diagnosis
Documents changes in a client's condition, events, and concerns
Three essential components:
- D: Data: Factual data about the client's condition
- A: Action: Nursing actions taken in response to the data
- R: Response: Client's response to the nursing actions
Includes immediate and future nursing actions.

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Description

This quiz covers the essentials of telehealth and the five phases of medication administration. It explores how communication technologies aid healthcare and details the critical steps involved in safely administering medication. Test your knowledge on these vital healthcare processes.