Study Guide RN 169 WK 3.docx

[Study Guide] **Ch.26 Informatics & Documentation** - **Documentation** - Key communication strategy - Produces a written account of patient data, clinical intervention and patient responses - Available to all members of the healthcare team - Allows others to...

[Study Guide] **Ch.26 Informatics & Documentation** - **Documentation** - Key communication strategy - Produces a written account of patient data, clinical intervention and patient responses - Available to all members of the healthcare team - 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 needed for quality and performance improvement - Serves as a resources for education and research **Interprofessional Communication Within the Medical Record (1 of 3)** - Legal documentation - Reimbursement documentation of patient care by all members of the health care team allows one to determine the severity of a patients illness, the intensity, of services received, and the quality of care provided during an episode of care. - Diagnosis-related groups (DRGs) are classifications based on a patients primary and secondary medical diagnoses that are used as the basis for establishing Medicare reimbursement for patient care provided by a health care agency, - Auditing and monitoring - As a member of the team, you are held accountable for the accuracy of the documentation you enter into the patients record. Audits of health records offer information on recurrent health care problems, specific patient incidents, and whether health care providerfs follow standards of care. **Interprofessional Communication Within the Medical Record (2 of 3)** - Electronic health record (EHR) - An individual's lifetime computerized record - Electronic medical record (EMR) - The record for an individual health care visit **Interprofessional Communication Within the Medical Record (3 of 3)** - **Maintaining privacy, confidentiality, and security of the health care record** - Protected health information (PHI) - **Privacy, confidentiality, and security mechanisms** - Firewall- is a combination of hardware and software that protects private network resources frm outside hackers, network damage, & theft or misuse of information. - Password - **Handling and disposing of information** - Procedures for nursing students It is essential to safeguard any information that's printed form the record or extracted for report purposes. Shred information - Policies for the use of fax machines **Standards and Guidelines for Quality Nursing Documentation (1 of 2)** - Guidelines for quality documentation AKA charting - Factual- Objective, avoid words like appears, seems, apparently - Accurate- using exact measurements establishes accuracy and helps you determine whether a patients condition has changed in a positive or negative way - Appropriate use of abbreviations- Use abbreviations carefully to avoid misinterpretation and promote patient safety. - Current- timely entries are essential in a patient's ongoing care, as delays in documentation can lead to unsafe patient care. Eg. Vital signs, pain assessment, administration of medications and treatments - Organized- concise, clear and to the point - Complete- be sure the information within a recorded entry or a report is complete, containing appropriate and essential information **Abbreviations** Use Instead Write "unit." Write "International Unit." Write "daily." Write "every other day." Write X mg. Write 0.X mg. Write "morphine sulfate." Write "magnesium sulfate." Eg 0.3 If it's a whole number don't use a decimal after a whole number **Standards and Guidelines for Quality Nursing Documentation (2 of 2)** Figure 26.2: Comparison of 24 hours of military time with the hourly positions for civilian time on the clock face. A clock showing the hands on the clock face set to 0300/1500 military time (3am/3pm civilian time).NOT IMPORtant **Methods of Documentation** - **Documentation of patient assessment data** - Flow sheets- nurses routinely document patient physiological data and routine care using flow sheets that are organized by body systems & navigated through use of the comp. mouse - Progress notes Health care team members monitor & record the progress made toward resolving a patient's problems in progress notes. - Charting by exception The philosophy behind is that all standards for normal assessment findings or for routine care activities are met unless otherwise documented.  **Common Record-Keeping Forms within the Electronic Health Record** - Admission nursing history form - Patient care summary - Care plans - Discharge summary forms Nurses help ensure cost-effective care & appropriate reimbursement by preparing patients for a safe, effective, & timely discharge from healthcare agency. **Acuity Rating Systems** - **Acuity rating system --** are used to determine the hours of care & number of staff required for a given grp of patinets every shift or every 24 hrs. pg 401 - 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 The acuity level it's a classification that compares one or more patients from 1 to 5. **Documentation in the Long-Term\ Health Care Setting** - **Governed by** - Individual state regulations - The Joint Commission (TJC) - Centers for Medicare and Medicaid Services (CMS) Notes: In documentation check for pain management **Informatics and Information Management in Health Care (1 of 3)** - **Health care information technology (HIT)** - Used to enhance quality and efficiency of care Is the use of info. Systems & other info. Technology to record, monitor, & deliver patient care, & to perform managerial & organizational functions in the health care. - **Health care information system (HIS)** - Two types: a clinical information system and an administrative information system Together these 2 types of systems operate to make the entry & communication of data & information more efficient. - **Clinical information system (CIS)** - Example: computerized provider order entry (CPOE) -this system allows health care providers to directly enter standardized, legible, & complete orders for patient care into a medical record frm any comp. in the HIS. Informatics and Information Management in Health Care (2 of 3) - Nursing clinical information systems (NCIS) - Two designs: 1 nursing model -- The nursing process its more traditional; this model incorporates the nursing principles of nursing informatics to support the work that nurses do by facilitating documentation of nursing process activities & offering resources for managing nursing ccare delivery and - 2 critical pathway -- or protocol; this design facilitates interprofessional management of information because all health care providers use evidence- based protocols or critical pathways to document the care they provide. - Advantages: better information access, better documentation quality, reduced errors of omission, reduced hospital costs, increased nurse job satisfaction, clinical database development NCIS has 2 - Clinical decision support systems (CDSS) - Aids and supports clinical decision making The knowledge base within a CDSS contains rules & logic statements that link information required for clinical decisions to generate tailored recommendations for individual patients; the recommendations are presented to health care providers as alerts, warnings, or other information for consideration. Informatics and Information Management in Health Care (3 of 3) - Nursing informatics - Specialty area of practice - Integrates nursing science, computer science, and information science - Informatics competencies for nursing graduates You need to be knowledgeable in the science and application of nursing informatics. **Ch 22 Ethics and Values** **Basic Terms in Health Ethics\*\*\*Memorize** - Morals- Judgement or Behavior based on beliefs - Value- A deeply held personal belief about the worth a person holds for an idea, custom, object - Bioethics- Branch of ethics in healthcare - Autonomy- Freedom of external control eg. Respect for patient autonomy refers to the commitment to include patients in decisions about all aspects of care. - Beneficence- A positive action to help others eg. The agreement to act with beneficience implies that the best interest of the patient remain more important than self-interest - Nonmaleficence- Avoidance of harm or hurt - Justice- Fairness and distribution of resources - Fidelity- Faithfulness and to keep promises Professional Nursing Code of Ethics - Code of ethics - Set of guiding principles that all members of a profession accept - Code of Ethics for Nursing - Key principles - Advocacy- refers to the application of one's skills & knowledge for the benefit of another person - Responsibility-a willingness to respect one's professional obligations and to follow through - Accountability- refers to answering for your own actions - Confidentiality- refers to the health care teams obligation to respect patient privacy Values - Value - Deeply held belief about the worth of an idea, attitude, custom, or object that affects choices and behaviors - Values clarification - To resolve ethical conflicts, one needs to distinguish among value, fact, and opinion. - Clarifying values---your own, your patients', your co-workers'--- is an important and effective part of ethical discourse. Nursing Point of View (1 of 2) - Types of ethical problems - Ethical dilemma- when two opposing courses of actions can both be justified by ethical principles eg. Lying to the patient to make them drink pills they need not want. - Moral distress-when taking a specific action while believing that action to be wrong - Ethics committees **Nursing Point of View (2 of 2)\*\*\*Memorize pg 322** - Processing an ethical problem - Step 1. Ask: Is this an ethical problem? - Step 2. Gather information that is relevant to the case. - Step 3. Identify the ethical elements in the problem and examine your values. - Step 4. Name the problem - Step 5. Identify possible course of action - Step 6. Create and implement an action plan and carry it out. - 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 and can provide you with emotional support when you encounter hardships at work. - Quality of life- is deeply personal - Care at the end of life- frequent source of ethical problems - Access to health care-is not always the case **Approaches to Ethics\*\*\*Memorize pg 319** - Deontology- Defines actions that are right or wrong based on their adherence to rules & principles such as fidelity to promises, truthfulness, & justice. Focuses on the act itself not so much the outcome. Decision maker detached, more objective. - Utilitarianism (less subjective-the greatest good for the greatest no. of people, focuses on outcomes. Decision maker detached, more objective - Casuistry- case-based reasoning, best actions that focuses on the details of a situation - Feminist ethics- Natural caring for others is the basis for moral behavior, concentrate more on practical situations & strong sense of responsibility. More subjective & judgemental, Emotional ettached - Ethics of care- Focuses on understanding relationships, personal narratives, & context which ethical problems arise. Emphasizes the role of decision maker in the situation. Nurses participate in with patient advocacy being top priority. Eg the action thats best for the relationship