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NURB230

Documentation

QuestionAnswer
Why do we use technology in nursing? -Record client information -Access other departments' information on the client from centralized computers -Bedside data entry: Client assessments, medication administration, progress notes, care plan updating, client acuity, accrued charges.
Computer-based patient records (or EMR) -Permits electronic client data entry and retrieval -Improves health care -constant availability of client health info -Ability to monitor quality -Access to warehoused data -Ability for clients to share in knowledge & activities
Patient Safety Type in orders instead of writing and risking illegible handwriting
Roles of the nurse informaticist -Combines computer science, information science with nursing science -Develops policies and procedures for the effective use of EMR and secure use of EMR
Clinical decision support systems -Incorporate evidence from literature into particular client situations. -Client-specific recommendations presented to clinicians for consideration -Alarms for when orders conflict (contraindicated treatments, allergies)
Data standardizations and classifications -Disease classifications (ICD, ICPC, and DSM) -Nursing classifications or taxonomies (NMDS and NANDA International) (HHCC, NIC, NOC and SNOMED CT) (May take years for determining body to take form)
Tracking client status -Retrieve and display client's physiological parameters across time. -Care plans/maps, critical pathways can be stored in computer and placed into the EHR
Client monitoring and computerized diagnostics -Used in every day practice -Digital or tympanic thermometers -Digital Scales -Pulse oximetry -ECG/telemetry/hemodynamic monitoring -Apnea monitors
Telemedicine/Telehealth -Transmits electronic data about clients to persons at distant locations (X-Rays, Scans, Stored Data) -Provides primary health care to people living in remote areas using monitors -Concerns regarding legal, ethical issues (state borders)
Created by: kimberlydanielle
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