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EBP, IT, and EMR

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Jessica Dwork

on 22 March 2018

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Transcript of EBP, IT, and EMR

Develop explanations (in theories)
Find solutions to problems
Improve care of people in clinical setting
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.
Where do I look?!?
It isn’t sufficient just to want; you’ve got to ask yourself what you are going to DO to get the things you want.
Frankiln Roosevelt

Patient, disease or condition of interest?

Intervention (treatment) of interest?
Comparison intervention of interest (if any)?
Outcome of interest? 
PICO questions...
Get others interested in Evidenced Based Nursing Practice
Components of a research article
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
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 :) )
Characteristics of Effective Documentation
Consistent with professional and agency standards
Legally prudent
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.
Breaching confidentiality
displaying info on screens
sharing printers
putting patient info in trashes
speaking loudly about patients
sending messages
A patient has the right to obtain, review, and revise the patient information in his or her health record.
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
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.

Whats the point of documenting?!?
Communication with other healthcare professionals
Record of diagnostic and therapeutic orders
Care planning
Quality of care reviewing
Decision analysis
Legal and historical documentation
Various nursing documents
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
Discharge summary
Shift, transfer, discharge, and telephone reports...
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.
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?
Federal regulations require that institutions receiving funding or conducting drug or medical device research regulated by the FDA have an IRB
IRBs are a group of individuals who review all research studies being conducted at an institution
IRBs determine risk factors associated with a study and ensure that ethical principles are followed
Types of orders....
Healthcare provider must sign order that was given verbally or over the telephone
Orders must be taken by registered professional nurses
Progress notes
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
Both subjective and objective
Interventions provided for the patient
Patient’s response to the interventions
Used to identify the nursing diagnosis requiring the interventions

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

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
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?
Improved efficacy
Reduced errors
Research and public health benefits
Planning care
Hand-off report
Bedside report
Face to face oral
Audio recorded
Easy to read
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.

Answer: B

Information regarding a patient’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 related to patient care and procedures may be of concern.
D. fragmentation of nursing and medical care procedures may be identified.

A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of:
A. PIE documentation.
B. SOAP documentation.
C. narrative charting.
D. charting by exception.

Admission nursing history form
Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems

Flow sheets and graphic records
Help team members quickly see patient trends over time and decrease time spent on writing narrative notes

Patient care summary

Standardized care plans or clinical care guidelines (CPGs)
Preprinted, established guidelines used to care for patients who have similar health problems

Discharge summary forms
Full transcript