Transcript: Standardization of orders Benefits of Nursing Informatics It enhances productivity Nursing Informatics is the "science and practice (that) integrates nursing, its information and knowledge, with management of information and communication technologies to promote the health of people, families, and communities worldwide." (IMIA Special Interest Group on Nursing Informatics 2009). The application of nursing informatics knowledge is empowering for all healthcare practitioners in achieving patient centered care. the END :) Physicians orders will be executed It reduces time transcribing duplicates Improved efficacy when ordering system It may have more time to take good care of their patients.
Transcript: " Integrates nursing, its information and knowledge and their management with information and communication technologies to promote the health of people, families and communities worldwide." Graves and Corcoran, 1989 $1.25 February, April 11, 2014 "A combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care." Nursing Informatics : A Definition International Medical Informatics Association, 2009 Vol XCIII, No. 311 Nursing Informatics
Transcript: What are the advantages and disadvantages with both the EHR and the paper record system? The components of nursing informatics practice include data, information, knowledge, and: a. cognition. b. enactment. c. wellness. d. wisdom. Have you witnessed any violations of HIPPA in your clinical practice or in your interaction with the health-care system? How could they be prevented? Please take out a sheet of paper and write your vision describing technology in health care in the year 2030. Thank you for your attention! What Do You Think? Capabilities of a Nurse Informaticists What are the importance of human factors in engineering on equipment design? Informatics nursing is distinguished from other nursing specialties by its focus on: a. computerizing medical records. b. data coding and the use of abbreviations. c. the content and representation of data and information. d. training and education. How does informatics promote evidence-based practice? Critical Thinking Exercises A Broader Definition Medical Informatics: include all the informational technolgoies that deal with the medical care of the client, medical resources, and the decision-making process. Health Informatics: the use of information technology with information management concepts and methods to support health-care delivery. Do you think technology's developmental rate is good or bad? Why? What ideas do you have that could improve nursing informatics? Nursing Informatics Data, Information, & Knowledge Discussion ?'s Nursing Informatics supports all areas of nursing, including practice, education, administration, and research. It facilitates and guides the management of data. When using technology, do nurses look to care or care to look? Are the 5 Rights Enough? Make the transition to a technologically advanced health care system smoother, more efficient, and safer for nurses and patients. Design information systems that optimize practitioner decision making. Develop and troubleshoot tools for consumer health care, such as health-related websites, homecare managment systems, remote monitoring, wearable monitoring devices, and telenursing. Promote health literacy through the design and development of tools and devices that bring health information to diverse populations. Engage in local and national policy debates over the need for more advanced health information technology. Data are defined as raw and unstructured facts. Information consists of data that have been given form and have been interpreted. Knowledge takes the process one step further by synthesizing data and information. Is now recognized as a nursing specialty for which an RN can receive certification. The Importance of Nursing Informcatics to Nursing Practice * Debate the ethical issues of personal privacy and the greater social good in relation to availability of health-care information. *Discuss how the design of equipment increases or decreases error rates. *Discuss uses of telehealth for patient teaching and monitoring of home health clients. List all the pieces of data you had to give at your last visit to the doctor or hospital. Was all the information necessary for your care? Who needed the information? How was the inforamtion recorded or transmitted? Nursing informatics is composed of computer science, information science, and nursing science. In newer models, cognitive science has been added. The ANA defines nursing informatics as a specialty that integrates nursing science, computer science, and information science in data and information to support nursing practice, administration, education and research; and to expand nursing knowledge. After noting differences in completeness of data between point-of-care and nursing station-based devices, the informatics nurse: a. forwards this information to the finance department. b. recommends that point-of-care systems be implemented institution-wide. c. reports the findings to the chief executive officer. d. suggests a research project to investigate the variances. Have you used computerized health-care records? Describe your experience. Defining Informatics What are Human Factors? What do you think some of the changes are in practice and health care delivery regarding technology infiltration? Nursing Informatics Three Basic Elements Additional Rights: 6. Documentation 7. Action 8. Form 9. Response Traditional Five Rights: 1. Patient 2. Drug 3. Route 4. Time 5. Dose Created By: Merry Jo & Kaitlin
Transcript: Benefits from care planning functionality NURSING INFORMATICS 간호정보학 Friday, May 02, 2014 The future development of nursing informatics : Discrete entities that are described objectively without interpretation WISDOM "The specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. Nursing Informatics facilitates the integration of data,information, and knowledge to support patients, nurses, and other providers in their decision-making in all roles and settings. " -American Nursing Association (ANA) (2001) Framework for Nursing Informatics REFERENCE KNOWLEDGE INFORMATION No.1 김정애(2000). 간호와 지식테크놀러지 . 경복논총 No.4 Eaves, Derek. (1996) Benefits of nursing information systems:Computer Bulletin. Mar1996, Vol. 38 Issue 2, p12-14. 3p. 강인순, 김명희. Development of Information System in Nursing Practice. 간호행정학회지 제2권 제2호 PLAY A VIDEO : Data that is interpreted, organized or structured Understanding, Applying, Applying with compassion : Information that has been synthesized so that interrelationships are identified and formalized NURSING INFORMATICS Interpreting, Integrating and Understanding Framework for Nursing Informatics Benefits from a departmental communication functionality In the future, not only the robot that help us with nursing procedures such as medication and physical assessment and information systems which solve the administrative functions of the nurse but also active decision support systems will be provided Information technology gives people a lot of time and more freedom by reliving the burdens in carrying out the tasks. It can not be exception in nursing, which make it possible for nurses to spend more time on the problems involved in each individual patient as pulling ourselves out of the daily routine and repetitive tasks and time-consuming chores. 경복대학교 4-A 김가영, 박효선, 이아영 Benefits from rostering functionality WHAT IS NURSING INFORMATICS? time saved on drug administration drugs more likely to be administered at prescribed times improvement in legibility of prescriptions improvement in quality of care Benefits from drug administration functionality Organizing and Interpreting Naming, Collecting, and Organizing less time spent on designing and amending rosters more accurate timesheets and personnel data quicker retrieval of personnel information less time spent on administration by managers Benefits from more efficient and effective communication time saved on telephone calls more efficient supplies ordering. more complete care plans reduction in time spent on care planning improved quality of care more complete assessments more complete evaluations facilitates multidisciplinary communication improved data quality facilitates improved discharge planning : The appropriate use of knowledge to manage and solve human problems. DATA
Transcript: The common factors that may have contributed are the increasing cost constraints in the mostly publicity financed healthcare systems, which have raised demands for cost-effective care and quality improvement. The professionalization of nursing, the effort to make nursing visible and aspirations for greater accountability have been additional influencing factors. One of the early initiatives that laid a foundation for terminology work in nursing was the concerned action on “ People’s needs for nursing care” by the WHO that was accomplished in many European countries in the 1980s (WHO, 1987). Belgium is the European country that has made nursing care most visible and where early on the contribution of nursing in healthcare has been acknowldged by national level policy makers. Since 1998, it is mandatory for all hospitals in the xountry to collect data four times per year, using the Belgian nursing minimum data set (B-NMDS). It is consists of 23 nursing interventions, medical diagnoses, patient demographics, nurse variables and institutional characteristics (Sermeus et al., 1994; Sermeus and deleis, 1997). IMIA's goals as a bridging organization: moving theory into practice by linking academic and research informaticians with care givers, consultants, vendors, and vendor-based researchers. leading the international medical and health informatics communities throughout the 21st century. Founded on 1976 The objectives of the European Federation for Medical Informatics are: · To advance international cooperation and the dissemination of information in health informatics · To promote high standards in the application of health informatics, · To promote research and development in health informatics · To encourage high standards in education in health informatics, and · To function as the autonomous European Regional Council of the International Medical Informatics Association (IMIA). In the Netherlands, a nursing information reference model (NIRM) has been developed to accommodate both the information needs of nurses at the clinical level and for aggregating data at higher levels. The model identifies a base level of patient data; a second level of interpretations and decisions by the nurse, including nursing diagnoses, interventions and outcomes; a third level of aggregated data on nursing diagnoses, interventions and outcomes for institutional purposes; and a fourth level of information aggregated for international sharing. Nurses in Denmark were early pioneers in the development of common terminology and informatics in Europe. Danish nurses inititiated the joint project, “Telenurse”, within the EU to promote standardization of nursing data in electronic health records (Mortensen, 1999). This project was later linked to the International Council of Nurses’ (ICN) project for development of an International Classification for Nursing Practice (ICNP). In Sweden it became mandatory for nurses to keep patient records in 1986. The VIPS model was developed with the purpose of conceptualizing the essential elements of nursing care, clarifying and facilitating systematic thinking and nursing recording. The nursing documentation model is based on the structure of the nursing process and in addtion includes other areas for which the nurse has responsibility and is accountable for recording. The focus of the model is on patients’ functioning in daily life activities rather than on pathophysiologic problems. Example of nursing informatics cooperation in europe Electronic identifiers: The Action Plan noted that “the need to identify a person unambi- guously is an important component” of any national or regional eHealth infrastructure. This applies not only to citizens/patients and healthcare professionals, but also to health- care providers and pharmacies. It is a central requirement to assure patient safety. Whereas patient identifiers (ID) were an element of eHealth strategies in most countries (24) in 2006 already and increased to 26 by now, the challenge of professional IDs was somewhat neglected till recently (mentioned by 13 countries only in 2006), but is now an acknowledged topic in 22 countries. Example of nursing informatics education in europe Is the ‘science and practice integrates nursing, its information and knowledge, with management of information and communication technologies to promote the health of people, families, and communities worldwide’ ( IMIA Special Interest Group on Nursing Informatics, 2009) Changes in Europe define by each member states in the European Union , and also with the E-Health initiatives and comparative data on the continent. Nursing Informatics groups update the use of terminologies and conduct Nursing Informatics Education throughout Europe. ePrescribing: This is another key application which 22 (+ 6 since 2006) Member States mention as a part of their national eHealth strategy, fully in line with the eH-AP objective that “European health organisations and health regions
Transcript: Documentation and Informatics "Nursing Informatics combines the best of computer science and information science with nursing science" EHR- Electronic Health Record is replacing the traditional printed medical record. does not reduce the responisbility for documenting clinical information accurately and completely in a timely manner. Nurses are legally and ethically obligated to keep information about clients confidential. HIPAA (Health Insurance Portability and Accountability Act) took effect in 2003, requiring that disclosure or requests regarding health information are limited to the minimum. Requires the clients consent before information is released and provides recourse if privacy protections are violated. ...STANDARDS... The TJC (The Joint Commission) standards require that all clients who are admitted to a health care institution have an assessment of physical, psychosocial, environmental, self-care, client education and discharge planning needs. "documentation must be systematic, continuous, accessible, communicated, recorded and readily available to all members of the health care team." ANA Records and Reports Reports include : client identification and demographic data, informed consent for treatment and procedures, medical history, diagnosis, therapeatic orders, discharge plan and summary Can be oral, written, or audiotaped and include change of shift reports, telephone reports, transfer reports, and incident reports Communication of the most current and accurate continuous source of information about a client’s health care status. provide data that you use to identify and support nursing diagnoses, establish expected outcomes of care plan, plan interventions, and evaluate the care according to client's response to the care provider Documentation should clearly state: 1. Goal-directed nursing care provided 2. What happened to the client 3. All assessments 4. Interventions 5. Client responses 6. Instructions 7. Referrals Common Charting Mistakes 1. Failing to record pertinent health or drug information 2. Failing to record nursing actions 3. Failing to record that medications have been given 4. Failing to record drug reactions or changes in clients condition 5. Writing illegible or incomplete records 6. Failing to document a discontinued medication $$ Payment systems known as DRG's are used for reimbursement for client care. Accurate documentation of supplies and equipment assists in accurate and timely reimbursement. Quality improvement programs keep nurses informed of standards of nursing practice to maintain excellence in nursing care. Quality documentation and reporting have five important characteristics : Factual, accurate, complete, current, and organized Contains descriptive, objective information about what a nurse sees, hears, feels and smells. Avoid using vague terms such as appears, seems or apparently. Document clients exact words The use of exact measurements establishes accuracy. Must have correct spelling, use an institutions accepted abbreviations, symbols and system of measurment to ensure all staff members are using the same language in their reports and records. All entries in medical records are dated and a method is established to identify the authors of entries. The signature holds that nurse accountable for the information recorded. All information must be complete, containing appropriate and essential information. Flow sheets offer means to enter current information quickly. Activities or findings to communicate at the time of occurrence include: 1. Vital Signs 2. Administration of medication and treatments 3. Preparation for diagnostic test or surgery 4. Change in client's status and who noticed 5. Admission, transfer, discharge, or death of a client 6. Treatment for a sudden change in client's status 7. Client's response to treatment or intervention Take time to assess all the information before beginning to write in the permanent record. Critical thinking skills and the nursing process gives logic and order to nursing documentation. Methods of Record Keeping Narrative: The traditional method for recording nursing care, uses a storylike format to document information Problem-Oriented Medical Record: A method of documentation that emphasizes the clients problems. Helps coordinate a common plan of care Database: Contains all available assessment information pertaining to the client. Is the foundation for identifying client problems and planning care Problem List: After analyzing data, health care team members identify problems and make a single problem list. Includes client's physiological, pschological, social, cultural, spirital, developmental, and environmental needs. Nursing Care Plan: Includes nursing diagnosises, expected outcomes and interventions. Progress Notes: Monitor and recording the progress of a client's problems. Source Records: The client's chart has separate section for each discipline to record data. Records things such as nursing, medicine, social
Transcript: Concerned about protecting patient privacy 1. Determine where patients may find information for electronic EMR access 2. Access patient awareness of electronic EMR access availability 3. Develop education flyer regarding electronic health record information for use at patient bedside Strengths 1. Evaluate the use of clinical practice guidelines on the unit 2. Review hospital policy on the use of clinical guidelines 3. Discuss areas of improvement for clinical guideline use in the EMR with nursing staff Competency Action Plan Ashley Walton Evaluate factors related to security and confidentiality of health information Informatics History Support the use of clinical guidelines into practice I have used Cerner PowerChart and EPIC informatics systems I have worked as a floor nurse for three years in both general medical and oncology Introduction 1. Review hospital policy on confidentiality and security of health information 2. Assess unit for areas of improvement in securement of patient information 3. Generate a plan on how to improve weak areas of secure handling of patient information Communication Competency Gaps Embrace technological change and focus on providing the best possible care and patient experience Persevere despite difficulties...Informatics is relatively new and there is much to learn Centralized storing of information allows for communication between all health care staff Second Goal Security Contact informatics nurse to gain more information on informatics topics related to each goal There are similarities and differences between the two programs. I have found both to have advantages and disadvantages Information is immediately available Self Assessment Nursing Informatics Steps on the Road to Increased Informatics Competency Quick Support clients' access to personal health information First Goal Reviewed informatics data in the interdisciplinary setting to improve nursing practice at the bedside I am attending my second semester at Gonzaga University and am just beginning the Post-Baccalaureate DNP program Many areas in which to develop knowledge to better serve my patients. Involved in past implementation of fall reduction and medication documentation projects No specific areas of competency recognized, minimal knowledge in some areas and little to none in others Third Goal Feelings on Informatics
Transcript: Using Technology Data gathering with computer systems allows patient information and evidence based research to be readily available for any and all practicing professionals at any time. Application of Informatics to Nursing Practice Data Integrity Video of Informatics Used in Health Care Information Literacy Information Quality Information Availability Confidentiality of information Ensure patient safety with proper diagnosis from accurate data Confidentiality of patient with proper storage and collection of data Requires on-going learning in development of computer proficiency in word processing, spreadsheet development, statistical analysis and use of web databases. Application of Informatics Nurses with a BSN are expected to utilize IT to obtain relevant data for appropriate care and implementing intervention with necessary knowledge derived with data received. Expectations of Baccalaureate Nurse Data collection Data validation Data storage Data management Data retrieval A strategy of incorporating technology to efficiently collect patient data and combine the data with knowledge to optimize patient care The Use of Informatics Nursing Informatics Capability of utilizing IT to collect, organize, store, and retrieve data for the appropriate patient Informatics allows for efficient procedures in organizing data and making data accessible for the best and safest quality of patient care References Quality Information Depends on: Hebda, T., & Czar, P. (2015, Oct 11). Handbook of Informatics for Nurses and Health Care Professionals. (5th ). Boston, MA, USA.
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