Nursing Informatics Study Guide - Finals PDF

 Nursing Informatics  Data Standards and Classifications What areas of nursing are involved with nursing – Disease classifications informatics? ICD, international classification of Primary Care...

 Nursing Informatics  Data Standards and Classifications What areas of nursing are involved with nursing – Disease classifications informatics? ICD, international classification of Primary Care ICPC, and DSM Nursing practice – the use of computer, – Nursing classifications or taxonomies information and technology for the benefit of NMDS ( Nursing Minimum Data Set) nursing care. - Careplan, assessment,dx,nic,noc Nursing education – for the ease of teaching and learning Nursing research – in expanding the knowledge  Record Keeping and understanding for the nursing profession Nursing administration – in managerial and Tracking client status – is the process of administrative work. retrieving and recording of patient data to be viewed across time. In the nursing process: Informatics is mostly Telehealth - Transmits electronic data about involved in which part? clients to persons at distant locations, consultations to remote areas are also made Nursing process = ADPIE possible. –Assessment: data gathering, keeping, E.H.R – a digital version of a patient’s paper recording chart.  What is Data? In creating The E.H.R and communication - Raw, uninterpreted: 180/90, 36.5 channels who should be involved? What are roles of nurses when it comes to data? - Clinicians (nurses, doctors) and - Technical experts - Collecting, recording and using that data for intervention and documentation. Health Information exchange – the cycle of information coming and going from and to the Is it part of a nurses job to interpret data to the communication channels. significant others of the patient?  Should you be charge for your copy of - Careful. Only doctors have the final medical record? authority to inform the family about the patient’s status especially sensitive ones. Yes. You are the owner of most of the data in the  Bedside Data Entry – is a collection of medical record. But the costs for recordkeeping, information about the patient and their finding and compiling your data requires progress, medications, procedure, care compensation hence the payment. plans even accrued charges (expenses done/rendered but not yet paid) Btw, who among the hospital have permit in electronic client data entry and retrieval? In big hospitals they have bedside terminals. - Doctors, nurses Do’s and Don’ts  Hospital communication systems involve the different areas into one program.  Be oriented with the machine so that you can put the patient at ease when using it. Patient monitoring system – mostly for doctors And to minimize frustrations seen by the and nurses to access patient care data patient Laboratory information system – medical  Address the client first before the machine technologists, radiology dept. laboratory  Explain what the computer is for technicians for requests and results  Assure confidentiality Pharmacy information system – for medication  Minimize interactions that can result in lists, combinations, contraindications etc. mistaken entries  Clinical Guidelines, Pathways, Protocol Proficient – has a holistic understanding of the situation. Able to make decisions for long term Guidelines: General principles that guide goals management and provide evidence-based information for specific clinical problems. Expert – able to accurately identify and solve the problem avoiding unnecessary alternatives. Clinical Guidelines are used: Has a deep understanding of the situation highly - To improve the quality of care for patients and fluid and flexible in the job. improve clinical effectiveness by implementation of evidence-based care in daily practice. - Can be developed either locally (internal  Professional Certifications for Nursing guidelines) or regionally or nationally (external Informaticist in the Philippines guidelines). - Certificate of Completion - A systematically developed statement to assist - Informatics Nurses Society of the Ph practitioner decisions about appropriate health - Informatics College Philippines care specific clinical circumstances. The entry level of Informatics Certification is: Certified Associate in Healthcare Information Ex. Guidelines for Medical Assessment and Management Systems (CAHIMS) No.1 Informed, No.2 With Consent, No.3 with Settings a Nurse Informaticist can work as: gender sensitivity consideration. - Nursing Informatics Clinician Protocols: Descriptions of specific steps to - Clinical Informatics Coordinator follow once a clinical management decision has - IT Clinical Nurse been made. Ex. Once the patient has expired the body will  Roles of Nurse Informaticists be transferred to the morgue after 1 hour. Clinicians – analyze and develop health systems - No watcher is allowed to stay more than used in clinical settings 15 mins inside the critical care unit. Educators – teach healthcare workers in using Pathways: Fall between guidelines and information systems, can teach in the community protocols, providing more specific behaviors to for family planning, guidance and counselling follow. It is a Multidisciplinary Plan of Care for and health promotion backed by research specific group of patients. Researcher  Proficiency/ Clinical Competence Case Manager - Coordination of services and What makes a nurse? personal development - Knowledge, Skills & Attitude Marketing Consultant – Market research involves identifying cost efficient way of running Only when you develop those 3 aspects can you the hospital. improve in the profession. Novice – no background, no experience Advance beginner- marginally demonstrates acceptable performance may need cues and supervision at times Competent – 2 to 3 years of experience in the area, confident and coordinated  Nurse Entrepreneur - A nurse who uses their training, knowledge and medical expertise as a  nurse to create and develop their own - Is an alphanumeric code used to identify businesses within the healthcare field a certain online journal or article in a unique way Entrepreneur vs Intrapreneur Intrapreneur : to individuals that manages and promotes product development and marketing  My PhilHealth Portal within a confine of a company or an association. 1. Look for the sticker if your hospital is My PhilHealth Portal ready Individuals in History linked to Entrepreneurship 2. Request from the designated hospital - Florence Nightingale: “First personnel to check entitlement of Entrepreneur” Started the first secular benefits nursing training in 1854 in England 3. The hospital personnel will inform you if you are entitled of the benefits. If yes, - Clara Barton: founded the American you can now enjoy your PhilHealth National Red Cross. Established the benefits. If no, the hospital personnel will Bureau of Records of Missing Army Men, inform you of the supporting documents 1881 you need to submit. - Mary Grant Seacole: started a hotel for wounded soldiers  Definitions: o Critical Care application: an area of  Entreprenurse expertise within nursing that focus specifically with human responses to life- - Project EntrepreNurse (2010): A project threatening problems. initiated by DOLE (Department of Labor and Employment) to facilitate o Community Health application: Emphasizes nurse entrepreneurship by giving the prevention of the disease, medical opportunities to unemployed licensed intervention and public awareness. nurse - o Ambulatory Care: or outpatient  Research care is medical care provided on an outpatient basis, including diagnosis, Inclusive, Bias free language observation, consultation, treatment, - Use singular “they” intervention, and rehabilitation services. Ex. A researcher’s career depends on how o Real-time outbreak and Disease often they are cited. surveillance system: is a system that provides early warning of possible infectious - Sensitivity to labels disease outbreaks caused by bioterrorism or Ex. Using “people of color” vs Black people other public health emergencies - Appropriate level of specificity o Medical Information Bus (MIB): Provides a generalized method of attaching patient Ex. Using “newborn” vs baby monitoring devices to a common interface. People aging 65-75 vs People over 65 years  DOI a.k.a Digital object identifier