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EBP, IT, and EMR

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Jessica Dwork

on 29 September 2016

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Transcript of EBP, IT, and EMR

EBP, IT, EMR
Develop explanations (in theories)
Find solutions to problems
Goals of Nursing Research
Improve care of people in clinical setting
Develop greater autonomy and strength as a profession
Provide evidence-based nursing practice
Steps of Research
Protecting Rights of Research Subjects
Informed consent
Federal regulations
Review boards
“The process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences."
Florence Nightingale was the first nurse researcher in the 1800’s.
A good question includes:
The situation
The intervention
The outcome
Where do I look?!?
Textbooks
Databases
It isn’t sufficient just to want; you’ve got to ask yourself what you are doing to DO to get the things you want.
Frankiln Roosevelt
P
Patient, disease or condition of interest?
i
Intervention (treatment) of interest?
c
Comparison intervention of interest (if any)?
o
Outcome of interest? 
Whats with all of this talk about PICO?!?
Get others interested in Evidenced Based Nursing Practice
Abstract
Introduction
Methods
Results
Discussion
References
Components of a research article
EBP
University of Minnesota (2000). Evidence-based health care project: Evidence based nursing. Retrieved from http://evidence.ahc.umn.edu/ebn.htm
“In a 55-year-old man with a 35-year-old history of chronic smoking, would the administration of bupropion as compared to a nicotine replacement therapy (NRT) be a better therapy in causing long-term abstinence from smoking?”
Give me a P....
Give me an I...
Give me a C...
Give me an O...
Nursing history
Policy development
Ethics
Education
Study people and the nursing process
1. Ask the clinical question
2. Collect the most relevant evidence
3. Critically review the evidence
4. Integrate all evidence with clinical expertise and patient preferences and values
5. Evaluate the decision or change
6. Share with others (easier said than done :) )
EMR
Characteristics of Effective Documentation
Consistent with professional and agency standards
Complete
Accurate
Factual
Organized
Timely
Legally prudent
confidential
Keeping it all private
All information about patients written on paper, spoken aloud, saved on computer
A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality.
True
False
Breaching confidentiality
displaying info on screens
sharing printers
putting patient info in trashes
speaking loudly about patients
faxes
sending messages
Question....
A patient has the right to obtain, review, and revise the patient information in his or her health record.
True
False
Patients do have rights!
See and copy their health record
Update their health record
Get a list of disclosures
Request a restriction on certain uses or disclosures
Choose how to receive health information
Types of orders
Verbal
Written
Telephone
Record order in chart
Read back all orders
Date and time all orders
Include doctors name who ordered followed by your name
Gettin down to the nitty gritty of medical orders...
Sign the orders with name and title
One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care.

True
False
Check it out....
Whats the point of documenting?!?
Communication with other healthcare professionals
Record of diagnostic and therapeutic orders
Care planning
Quality of care reviewing
Research
Decision analysis
Education
Legal and historical documentation
Reimbursement
There are just too many types!
SOAP
DAR
pIE
CHARTING BY EXCEPTION
Which of the following methods of documentation is unique in that it does not develop a separate plan of care but instead incorporates the plan of care into the progress notes?
Source-oriented records
Problem-oriented records
PIE (problem, intervention, evaluation)
Focus charting
Test your knowledge
Various nursing documents
Initial nursing assessment
Kardex and patient care summary
Plan of nursing care
Critical collaborative pathways
Progress notes
Flow sheets
Discharge and transfer summary
Types of Flow Sheets
Graphic record
24-hour fluid balance record
Medication record
24-hour patient care records and acuity charting forms
PIE notes, SOAP notes, focus charting, and charting by exception are examples of which of the following formats for nursing documentation?
Collaborative pathways
Progress notes
Flowsheets
Discharge summary
Shift, transfer, discharge, and telephone reports.....oh no
SBAR
Situation
Background
Assessment
Reccomendations
Can you repeat the ?
Shall we look at this more closely?!?
Lets go have some fun!
A decision making model based on the conscientious, explicit, and judicious use of current best practice in making decisions in the care of individual or groups of patients
Motacki, K. (2011). Nursing Delegation and Management of Patient Care. St. Louis : Mosby.
DO NOT EXCEPT STANDARD PRACTICES
Nurses must ask themselves some very important questions.....
Why are we doing it this way?
Is there a better way?
Is there any evidence supporting this practice?
What if we try a different way?
Would that way be just as effective?
What is best practice?
CINAHL
Medline
Cochrane
Federal regulations require that institutions receiving funding or conducting durg or medical device research regulated by the FDA have an IRB
IRBs are a group of individuals who review all research studies being ccnducted at an institution
IRBs determine risk factors associated with a study and ensure that ethical principles are followed
True
True
True
Types of orders....
Verbal
Telephone
Written
Healthcare provider must sign order that was given verbally or over the telephone
Orders must be taken by registered professonal nurses
PIE
Progress notes
nURSING CARE CONFERENCES
NURSING CARE ROUNDS
Nurses are legally and ethically obligated to keep client information confidential.
Nurses are responsible for protecting records from all unauthorized readers.
The Joint Commission requires each client have an assessment:
Physical, psychosocial, environment, self-care, client education, and discharge planning needs
Information regarding a client’s health status may not be released to non–health care team members because:
A. Legal and ethical obligations require health care providers to keep information strictly confidential.
B. Regulations require health care institutions to document evidence of physical and emotional well-being.
C. Reimbursement issues relating to patient care and procedures may be of concern.
D. A fragmentation of nursing and medical care procedures may be identified.
A. Legal and ethical obligations require health care providers to keep information strictly confidential.
A nurse has just admitted a client with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record:
C. Lengthy entry using lay terminology
B. Objective data that are observed
D. Abbreviations familiar to the nurse
A. An interpretation of client behavior
B. Objective data that is observed
S- “I can’t get to my bath supplies because my strength is gone. I can’t even move myself”
O- Pt. unable to lift arms above chest. Washed own hands and upper chest slowly. Muscle strength 3/6 on upper and lower extremities. Pt. remains on bed rest
A- Self care deficit, bathing and hygiene
P- Continue to provide for pt’s bathing and hygiene needs. Assess and instruct family regarding alternate methods for meeting bathing and hygiene needs
Data
Both subjective and objective
Action
Interventions provided for the patient
Response
Patient’s response to the interventions
Problem
Used to identify the nursing diagnosis requiring the interventions

Intervention
The actions that you took and any assessment data related to the interventions

Evaluation
The results of your interventions and any additional information regarding attaining your outcomes
A documentation method that requires the nurse to document only deviations from pre-established norms
Exceptions are the only narrative notation

Subjective data
objective data
Assessment- symptoms/diagnosis
Plan- interventions, plan of care
Charting by exception
Do’s of Charting
Check to be sure you have the correct chart before you begin writing
Make sure your documentation reflects the nursing process and your professional capabilities.
Chart completely
Be concise and accurate
Chart time for each entry
Document PRN medications and exceptional things in the record
Include the following for procedures: what was done, when it was done, who did it, how it was done, how the client tolerated it, adverse reactions, if any. Paint a clear picture of what happens
Record each phone call to or from a physician, including exact time, message, and response.
Chart when a doctor makes a visit, and if there are any new orders
Chart as soon as possible after providing care
Chart a client’s refusal of treatment or medications
Chart client’s subjective data.. ( what he says and how he says it) use quotations if necessary
If you remember something important after you have completed your documentation, write “ late entry” and make the note
If information on a flow sheet does not pertain to your patient, write N/A for not applicable, leaving it blank appears that it was not addressed or an oversight
Don'ts of Charting
Don’t chart a symptom such as “c/o Pain” without also writing what you did about it
Don’t alter a chart….this is a criminal offense
Don’t add information at a later date without indicating that you did so
Don’t date the entry so that it appears to have been written at an earlier time
Don’t use shorthand or abbreviations that are not standard
Don’t write vague descriptions such as “ large amount of drainage”
Don’t make excuses, such as “meds not given because not available.”

Don’t chart what someone else says unless you use quotations and state who said it
Don’t chart an opinion
Don’t use words that suggest a negative attitude, such as “weird” or “nasty”
Don’t chart ahead of time. If something happens it will look bad to go back and make that correction
Misspelled words and bad grammar are as bad as illegible handwriting
Don’t record staffing problems
Don’t document that an incident report was completed
Don’t record staff conflicts

For patients with impaired skin integrity related to urinary incontinence, would applying a barrier cream as compared to washing with soap and water, rinsing well and air drying after incontinent episodes prevent or achieve less perineal excoriation?
Benefits:
Improved efficacy
Privacy
Accessibility
Reduced errors
Research and public health benefits
Planning care
http://youtu.be/MWK9DmmenIQ
Source-oriented
POR
Narrative note
Hand-off report
Bedside report
Face to face oral
Audio recorded
Easy to read
pico qUESTION.....
Delegation
Transfers responsibility while remaining accountable for outcomes
Requires knowing which skills are transferable
Results in improved quality of patient care, improved efficacy, increased productivity, and an empowered staff

The Five Rights of Delegation
Right Task
Right Circumstance
Right Person
Right Direction
Right Supervision

A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to:

A. Assign only bed-making and feeding skills.
B. Assess the knowledge of the certified nursing assistant.
C. Remind the staff member that she is working under the license of the RN.
D. Allow the staff member to perform only skills that the RN is able to teach certified nursing assistants to perform.

Did I do that?!?
Answer: B
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