Electronic Health Documentation and Its Impact on Nurses Routine Practices
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Nursing Documentation in Clinical Practice
From the Department of Nursing, Karolinska Institutet, Stockholm, Sweden Nursing Documentation in Clinical Practice Instrument development and evaluation of a comprehensive intervention programme Catrin Björvell Stockholm 2002 Nursing Documentation in Clinical Practice Instrument development and effects of a comprehensive education programme By: Catrin Björvell Cover layout: Tommy Säflund Printed at: ReproPrint AB, Stockholm ISBN 91-7349-297-3 NURSING DOCUMENTATION IN CLINICAL PRACTICE There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle than to initiate a new order of thing. Machiavelli, The Prince Nursing documentation in clinical practice Instrument development and evaluation of a comprehensive intervention programme Catrin Björvell, Department of Nursing, Karolinska Institutet, Stockholm, Sweden Abstract The purpose of this study was to describe and analyse effects of a two-year comprehensive intervention concerning nursing documentation in patient records when using the VIPS model - a model designed to structure nursing documentation. Registered Nurses (RNs) from three acute care hospital wards participated in a two-year intervention programme, in addition, a fourth ward was used for comparison. The intervention consisted of education about nursing documentation in accordance with the VIPS model and organisational changes. To evaluate effects of the intervention patient records (n=269) were audited on three occasions: before the intervention, immediately after the intervention and three years after the intervention. For this purpose, a patient record audit instrument, the Cat-ch-Ing, was constructed and tested. The instrument aims at measuring both quantitatively and qualitatively to what extent the content of the nursing process is documented in the patient record. -
Clinical Case Management Practice
chapter 2 CliniCal Case ManageMent PraCtiCe “I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results.” —Florence Nightingale Case managers focus on care coordination, financial management, and resource utilization to yield cost-effective outcomes that are patient-centric, safe, and provided in the least restrictive setting. When case management is practiced in this manner, costs are contained and patients, families, and stakeholders are viewed as essential members of the team. Case management is a fluid and dynamic practice that is most effective when it changes and adapts with the challenges of the healthcare system. Stewardship of the healthcare dollars, safe transitions of care, evaluating patient adherence, and consistent stakeholder communication are critical interventions that case managers employ, while maintaining a primary and consistent focus on quality of care and patient self-determination. 22 NursiNg Case MaNageMeNt review aNd resourCe MaNual, 4th editioN Case management is not a new concept. It traces its history back to the early 1900s, when it simply functioned as a means of providing care and containing healthcare costs. In the 1920s, the practice found its roots in the fields of psychiatry and social work, and focused on long- term chronic illnesses that were managed within the community. Case management processes were also used by visiting and public health nurses in the 1930s, when making house calls was a common practice. Throughout the next 50 years, case management remained essentially in the community. The mid-1980s saw the introduction of prospective payment system (PPS) case management, which became widespread within the acute and post-acute settings (Cesta, Tahan, & Fink, 2002). -
Nursing Informatics: the Future Now
IOSR Journal of Nursing and Health Science (IOSR-JNHS) e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 3, Issue 2 Ver. IV (Mar-Apr. 2014), PP 51-53 www.iosrjournals.org Nursing Informatics: The Future Now Mamta M.Sc Nursing (Community Health Nursing), M.Sc Applied psychology, PGD Health, Family Welfare & Population education. Nursing Tutor, College of Nursing, AIIMS, Jodhpur Abstract: Technological advancements in the health care field have always impacted the health care disciplines in a way they are being practiced. Nursing practice has also been greatly influenced by the technology a lot. In the recent year’s use of information technology, computers, handheld digital devices, internet has advanced the nursing by bridging the gap from nursing as an art to nursing as science. In every sphere of nursing practice, nursing research and nursing education nursing informatics plays a very important role. If used properly it is a way to save time, helps to provide quality nursing care and increases the proficiency of nursing personnel. Key words: Nursing Informatics, Nursing Information System I. Introduction Nursing informatics is a relatively new area and speciality of nursing. It is a rapidly developing area of nursing that has been recognized as a profession.1With the consideration that today’s nurses spend up to 50% of their work time only in documentation, Information technology and computerization comes to their saviour.2,3 Being recognized by American Nurses Association in 1992, nursing informatics is defined as a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. -
Role of Information Technology in Nursing
Cumhuriyet Üniversitesi Fen Fakültesi Cumhuriyet University Faculty of Science Fen Bilimleri Dergisi (CFD), Cilt:36, No: 3 Özel Sayı (2015) Science Journal (CSJ), Vol. 36, No: 3 Special Issue (2015) ISSN: 1300-1949 ISSN: 1300-1949 Role of information technology in nursing Shahnaz ISMAILZADH1*, Yousef MAHMOUDIFAR2 1Student computing, Mahabad Branch, Islamic Azad University, Mahabad, Iran 2Department of Nursing, Mahabad Branch, Islamic Azad University, Mahabad, Iran Received: 01.02.2015; Accepted: 05.05.2015 ______________________________________________________________________________________________ Abstract. Nursing information system development such as the impact on the workload, planning and working methods of communicating between multiple jobs care organizations to meet the challenges associated with it. This study aimed to investigate nurses' experiences of their impact on the performance of nursing is nursing information. Most nurses effect on speeding up information systems in nursing, having more time for patient care, easy exchange of information between parts had experienced. They believed that when clinical information into the computer at the same time they cannot care and there was duplication in data entry. Between some demographic characteristics of computer literacy and experience of nurses and there was a significant relationship. Information and communication technologies along with community-wide health promotion, due to a change in the quality of health care has become. The main field of application is remote care information technology, based on developments within health systems, and changing attitudes of health-oriented perspective, and a community-oriented and based on the quality of health services. Despite the widespread penetration of advanced technologies in the field of health, ranging from diagnosis and treatment - treatment and medical education ict because of the challenges facing not been able to find its place fully in this area. -
Informatics and Technology in Professional Nursing Practice
© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Informatics and Technology in 14 © JonesProfessional & Bartlett Learning, Nursing LLC Practice© Jones & Bartlett Learning, LLC NOT CathyFOR K.SALE Hughes OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & BartlettHealthcare Learning, delivery LLC largely depends on information© Jones for & Bartlett Learning, LLC NOT FOR SALE effectiveOR DISTRIBUTION decision making. Every nursing actionNOT relies FOR on SALE OR DISTRIBUTION knowledge based on information. The nursing process begins with obtaining and communicating information in the initial As we enter the era of the and ongoing assessment. Nursing informatics (NI) is the man- electronic health record agement of data, information, knowledge, and wisdom rel- (EHR), NI has become an evant to nursing© Jones(American & Nurses Bartlett Association Learning, [ANA], LLC 2008). indispensable© elementJones &in Bartlettthe Learning, LLC As we enter theNOT era ofFOR the electronic SALE ORhealth DISTRIBUTION record (EHR), NI practiceNOT of nursing. FOR SALE OR DISTRIBUTION has become an indispensable element in the practice of nursing. All nurses utilize informatics skills in their practice. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTNursing FOR SALE InformaticsOR DISTRIBUTION Defined NOT FOR SALE OR DISTRIBUTION Nursing informatics (NI) is together a field of study and an area ofspecialization. In the mid-1900s, NI was first identified as the use of information technology Learning Objectives © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION After completing this chapter, the student should be able to: 1. -
Why Do Nurses Need Philosophy?
International Journal of Sciences: Basic and Applied Research (IJSBAR) ISSN 2307-4531 (Print & Online) http://gssrr.org/index.php?journal=JournalOfBasicAndApplied -------------------------------------------------------------------------------------------------------------------------- Why do nurses need philosophy? Dewi Prabawati* Sint Carolus School of Health Sciences, Jakarta, Indonesia Email: [email protected] Abstract The nature of philosophy gives a significant influence on the way nurse examines the phenomena which happen on the field. Together with nursing ethics, it is needed for nursing practice, as the basic elements of rights, giving value and the nature to perform good nursing practice. Philosophy and science can’t be separated because they give mutual benefits each other; where science requires philosophy to connect its findings for human knowledge and philosophy can act as a language connecting disciplines. Philosophy will increase nurses’ ability to understand the phenomena and this will provide nurses with a way to think about their practice. Caring is expected to be a spirit of nursing, and through caring, nurse can provide a safe and compassionate nursing care. For nurse educator, caring is a soul of nursing that will help the students cope or make adaptation with the stressor, thus will increase their motivation to study nursing. Keywords: Philosophy; nursing practice; science; caring. 1. Introduction Nursing is a discipline embedding science and art. As science, nursing has the body of knowledge that serves as rational for nursing practice; and as an art, nursing embodies effort to express the creativity in providing nursing care. Based on that definition, question that may arise is: why do nurses need philosophy? To answer this question and to know about the relationship, this paper attempts to provide the answers and it is believed that nurses need to understand the nature and the value of philosophy. -
The Benefits of Using Standardized Nursing Terminology
Page 1 of 20 Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care By Cynthia B. Lundberg, R.N., BSN; SNOMED Terminology Solutions; Judith J. Warren, PhD, RN, BC, FAAN, FACMI; University of Kansas; Jane Brokel, PhD, RN, NANDA International; Gloria M. Bulechek, PhD, RN, FAAN; Nursing Interventions Classification; Howard K. Butcher, PhD, RN, APRN, BC; Nursing Interventions Classification; Joanne McCloskey Dochterman, PhD, RN, FAAN; Nursing Interventions Classification; Marion Johnson, PhD, RN; Nursing Outcomes Classification; Meridean Maas PhD, RN; Nursing Outcomes Classification; Karen S. Martin, RN, NSN, FAAN; Omaha System; Sue Moorhead PhD, RN, Nursing Outcomes Classification; Christine Spisla, RN, MSN; SNOMED Terminology Solutions; Elizabeth Swanson, PhD, RN; Nursing Outcomes Classification, Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, Association of PeriOperative Registered Nurses Citation: Lundberg, C., Warren, J.., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Johnson, M., Mass, M., Martin, K., Moorhead, S., Spisla, C., Swanson, E., & Giarrizzo-Wilson, S. (June, 2008). Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care. Online Journal of Nursing Informatics (OJNI), 12, (2). Available at http:ojni.org/12_2/lundberg.pdf Page 2 of 20 Abstract Using standardized terminology within electronic health records is critical for nurses to communicate their impact on patient care to the multidisciplinary team. The universal requirement for quality patient care, internal control, efficiency and cost containment, has made it imperative to express nursing knowledge in a meaningful way that can be shared across disciplines and care settings. The documentation of nursing care, using an electronic health record, demonstrates the impact of nursing care on patient care and validates the significance of nursing practice. -
Nursing Telehealth Practice – RN, LPN, NT, and NA
Advisory Opinion: NCAO 25.00 Nursing Telehealth Practice – RN, LPN, NT, and NA Department of Health Nursing Care Quality Assurance Commission Advisory Opinion An advisory opinion adopted by the Nursing Care Quality Assurance Commission (NCQAC) is an official opinion about safe nursing practice (WAC 246-840-800). The opinion is not legally binding and does not have the force and effect of a duly promulgated regulation or a declaratory ruling by the NCQAC. Institutional policies may restrict practice further in their setting and require different expectations to assure their patients’ safety and decrease risk. Title: Nursing Telehealth Practice: Registered Nurse, Number: NCAO 25.00 Licensed Practical Nurse, Nursing Technician, and Nursing Assistant References: See References and Resources (Page 5-6) Contact: Deborah Carlson, MSN, RN, Director of Nursing Practice Phone: 360-236-4703 Email: [email protected] [email protected] Effective Date: March 12, 2021 Supersedes: Telehealth/Telenursing for Nurses (Undated) Approved By: Nursing Care Quality Assurance Commission (NCQAC) Conclusion Statement The appropriately trained and competent registered nurse (RN), licensed practical nurse (LPN), nursing technician (NT), and nursing assistant-certified/nursing assisted-registered (NA-C/NA- R) may perform telehealth nursing care using telehealth technologies within their legal scope of practice, regulatory requirements, and practice standards. The individual must be credentialed in Washington State to provide telehealth nursing services to individuals/patients located in Washington unless a qualified exception applies. The individual providing telehealth services to patients located in other states, U.S. territories, or countries must comply with licensing, practice requirements, and laws and rules for that jurisdiction. -
Nursing, Technology, and Information Systems
SPECIAL REPOR T: Nursing, Technology, and Information Systems This special report is sponsored by Cerner Corporation and the Healthcare Information and Management Systems Society (HIMSS). All articles contained in this special report have undergone peer review according to American Nurse Today standards. s m e t Enabling the ordinary: More time to care s y S Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, and Susan Hamer, DEd, MA, BA, RGN n o i t a Versions of this article appear in Nursing is what nurses do, m American Nurse Today and what nurses do is coordi - r (United The value of o States) and Nursing Times (Unit - nate and deliver care. So al - f n ed Kingdom) to acquaint readers though the context, technology, I technology in with common goals, challenges, and health needs of our popula - d tions have changed, nurses re - n and advances in using health in - automating and a main the foremost providers and , formation technology to enable y nurses to provide safer and more coordinators of care. g improving Why state something so obvi - o efficient care. l ous? Showcasing the caring o n patient care aspects of nursing in a techno - h logically dominated world is c e — challenging. Technology enables T , round the globe, in care and enhances safety by au - g every setting, nurses seek ening issues come to the fore - tomating functions both simple n i Ato provide care to pa - front. On the other hand, in the and complex. It doesn’t replace s r tients and families to keep them United Kingdom (UK), the de - nurses. -
Standard Nursing Terminologies: a Landscape Analysis
Standard Nursing Terminologies: A Landscape Analysis MBL Technologies, Clinovations, Contract # GS35F0475X Task Order # HHSP2332015004726 May 15, 2017 Table of Contents I. Introduction ....................................................................................................... 4 II. Background ........................................................................................................ 4 III. Landscape Analysis Approach ............................................................................. 6 IV. Summary of Background Data ............................................................................ 7 V. Findings.............................................................................................................. 8 A. Reference Terminologies .....................................................................................................8 1. SNOMED CT ................................................................................................................................... 8 2. Logical Observation Identifiers Names and Codes (LOINC) ........................................................ 10 B. Interface Terminologies .................................................................................................... 11 1. Clinical Care Classification (CCC) System .................................................................................... 11 2. International Classification for Nursing Practice (ICNP) ............................................................. 12 3. NANDA International -
Practice Directive Documentation Standards
Practice Directive Documentation Standards College of Registered Nurses of Prince Edward Island December 2020 Approved by CRNPEI Council Dec 10, 2020 Introduction The College of Registered Nurses of Prince Edward Island (CRNPEI) and the College of Licensed Practical Nurses of Prince Edward Island (CLPNPEI) are legislated to serve and protect the public interest through the regulation of individual registered nurses (RN), nurse practitioners (NP) and licensed practical nurses (LPN). For the purposes of this document the term nurse(s), will refer to all three designations of nurses in Prince Edward Island. Nurses in Prince Edward Island are accountable to practice within their Code of Ethics, Standards of Practice, and to meet established agency practice policies and procedures. As self-regulating professions, Nurses are regulated under the authority of the Prince Edward Island Regulated Health Professions Act (2013) and corresponding regulations, which outline the accountabilities and responsibilities of Nurses. This includes a Nurses’ legal responsibility to practice within their scope of practice and level of competence. Nurses must know what they are authorized and competent to perform, including any limitations in skill, knowledge, and judgement to ensure their practice is within their scope. Nursing documentation is a vital component of safe, ethical and effective nursing practice, regardless of the context of practice or whether the documentation is paper- based or electronic. Purpose The purpose of this practice directive is to set a standard for how nurses should document within their practice while remaining accountable to the CRNPEI Standards of Practice, and the Regulated Health Professions Act (RHPA). This document describes nurses’ accountability and the expectations for documentation in all practice settings, regardless of the documentation method or storage. -
Telehealth/Telenursing for Registered Nurses 1
Nursing Care Quality Assurance Commission PO BOX 47864 i Olympia Washington 98504-7864 Tel: 360-236-4725i Fax: 360-236-4738 Telehealth/Telenursing For Registered Nurses 1. Telephone triage and nursing consultation by telephone or other electronic technology, incorporates unique knowledge, skill and competencies. Nurses employ the full range of the nursing process to gather data, make assessments, and generate plans for care via telephone encounters with patients. 2. Protocols are appropriate tools for implementing treatment plans. A registered nurse may use a protocol that has been written and approved by a physician to initiate a standing order for a medication or treatment. Assuming an appropriate patient-prescriber relationship exists, authorized standing orders may be implemented without consulting an authorized prescriber for a particular patient. The registered nurse should implement only standing orders which include a target population, exclusions, the population served, contraindications, special considerations, a specific order, a description of who has the authority to implement the order, physician signature, and review and approval by nursing as well as other involved disciplines. 3. Practice guidelines and protocols for care should be developed based on scientific/empirical evidence and outcomes data or expert opinion. Methods for periodic review of these tools to evaluate care effectiveness and currency of information should be in place. 4. Practice guidelines should evolve through collaboration and professional consensus among all involved health care disciplines. 5. When functions of the nurse involve complex decision making, even when driven by algorithm and protocol, telenursing should be limited to the practice of registered nursing. Licensed practical nursing activities within this context may include information gathering and the provision of patient education.