Documentation
is a key communication strategy that produces a written account of pertinent patient data, clinical decisions and interventions, and patient responses in a health record.
health record
Primary function is to store patient care documentation. Other functions include assisting in assigning diagnoses, assisting in choosing treatment. **
Health record contains the who, what, when, where, why and how.
**
Diagnosis-related groups (DRGs)
are classifications based on a hospitalized patient's primary and secondary medical diagnoses that are used as the basis for establishing Medicare reimbursement for patient care.
meaningful use
a set of government mandated criteria that must be obtained for every patient
electronic health record system (EHRS)
results in improved quality, safety, and efficiency of health care; increases health care consumers' active involvement in their care; increases coordination of health care delivery; advances public health; and safeguards the privacy and security of perso
electronic medical record (EMR)
refers to a patient's record within an integrated health care information system for an individual visit to a health care provider's office or for an individual admission to an acute care setting that allows for seamless documentation of the progression o
protected health information (PHI)
Any information about health status, provision of health care, or payment for health care that can be linked to an individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history.
firewall
is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information.
password
is a collection of alphanumeric characters and symbols that a user types into a computer sign-on screen before accessing a program after the entry and acceptance of an access code or user name.
accreditation
official authorization or approval for conforming to a specified standard
flow sheets
(graphic records)
Documentation tools used to record routine aspects of nursing care.
charting by exception (CBE)
is that all standards for normal assessment findings or for routine care activities are met unless otherwise documented.
Standardized care plans
or clinical practice guidelines (CPGs) to facilitate the creation and documentation of a nursing and or interprofessional plan of care
incident report
(occurrence report) is completed whenever an incident occurs.
acuity rating systems
to determine the hours of care and number of staff required for a given group of patients every shift or 377every 24 hours.
case management
model incorporates an interprofessional approach to delivery and documentation of patient care
Critical pathways
(also known as clinical pathways, practice guidelines, or CareMap tools) are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame
variances
Unexpected outcomes, unmet goals, and interventions not specified within a critical pathway
Health information technology (HIT)
is the use of information systems and other information technology to record, monitor, and deliver patient care, and to perform managerial and organizational functions 378in health care
health care information system (HIS)
consists of "computer hardware and software dedicated to the collection, storage, processing, retrieval, and communication of patient care information in a healthcare organization
clinical information system (CIS)
(also known as a patient care information system) is a large, computerized database management system that is used to access patient data needed to plan, implement, and evaluate care
computerized provider order entry (CPOE)
computerized provider order entry (CPOE) system that allows health care providers to directly enter standardized, legible, and complete orders for patient care into a medical record from any computer in the HIS.
nursing clinical information system (NCIS)
incorporates the principles of nursing informatics to support the work that nurses do by facilitating documentation of nursing process activities and offering resources for managing nursing care delivery
clinical decision support system (CDSS)
is a computerized program that aids and supports clinical decision making.
Nursing informatics
Nursing informatics is the specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing and informatics practice
health care informatics
the use of information technology with information management concepts and methods to support the delivery of health care (includes medical informatics)
1. The nurse contacts a provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the f
2. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record.
2. The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that appl
1. Using a strong password and changing your password frequently according to agency policy
3. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a loc
3. When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-10
3. Charting-by-exception (CBE)
4. The nurse works at an agency where military time is used for documentation, and needs to document that a patient was transported to the operating room for an emergency procedure at 8 in the evening. Point to the area on the clockface below that indicat
2000
5. The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's electronic health record must be printed and faxed to the acute rehabilitati
1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax.
2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read th
6. The nurse is administering a dose of metoprolol to a patient, and is completing the steps of bar code medication administration within the EHR. As the bar code information on the medication is scanned, an alert that states "Do not administer dose if ap
3. Clinical decision support system (CDSS)
7. The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O):
1. April 24, 2019 (0900)
2. Repositioned patient on left side.
3. Medicated with hydrocodone-acetaminophen 5/325 mg,
O: 1, 2, 3, 5, 6, 7. S: 4
8. The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record?
1. CPOE reduces the time necessar
4. CPOE improves patient safety by reducing transcription errors.
9. The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission's "Do Not Use
4. Insulin aspart 8u SQ every morning before breakfast
10. The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts th
4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN