Info Tech, Quality Improvement, EBP
> Informatics - use of info & tech to communicate, manage
>
quality assurance - evaluates client
knowledge, mitigate error, support decision making outcomes and ensure standards being upheld
for client safety and health
>
- Nursing informatics - integration of tech & physical devices w/ >
- lean approach - decreasing amount of
nursing knowledge & nursing clinical decision-making skills waste (resources, time)
> documentation
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• eliminate repeated, unnecessary steps
• subjective data - document as direct quotes, support by that add time delay
objective data > six sigma - reduce variations in practice,
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• objective data - descriptive, what nurse sees, hears, feels, reduce errors
smells; should not include judgement, opinions • 5 steps: define problem, measure
• accurate and concise - document facts, info precisely (observations, statistics), analysis,
- without interpretation of situation, unnecessary words, improvements created, control
irrelevant details, use exact measures, only approved >
- national datas of nursing quality indicators
abbreviations (NDNQI)
• complete and current - comprehensive and timely, never • survey of nurses to identify hospital
chart before doing it, no "will continue to monitor" nursing concerns, ways to promote
• all entries have date/time, should reflect assessments, change, QI
interventions, evaluations - quality of care, workplace
•↳ formats improvement
>
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10 core competencies (KSA)
- flow charts: show trends in vitals, blood glucose levels, pain
level, frequent assessments
- narrative documentation: records info in sequence in story
manner
- charting by exception: standardized forms that identify
norms and allows selective documentation of deviations from
norms
- problem oriented med records: organized by problem/
diagnosis and consists of a database, problem list, care plan,
progress notes (SOAP, PIE, DAR)
> giving effective report
- > Risk management - reducing risk of errors by i
• significant info about health problems, logical sequence, no • understanding causes, change culture with
personal opinions, recent changes in status, meds, communication and collaboration
treatments, procedures, discharge plan - root cause analysis (RCA) - joint commission
> Telephone/verbal orders
• determine what happened, how to prevent
• have second nurse listen, repeat back med name, dosage,
time, route, question,, provider sign in person in time frame never events - errors that are identifiable,
>
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- incident reports
preventable, potential for serious risk
• incident - occurence of accident or unusual event (ie. Med • reveals problems in safety, credibility of
errors, falls, needlesticks) health care facility
• document with facts not opinion, do not refer to in medical
>
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sentinel event - unsafe practice that resulted in
record; describe what you saw, include full names extreme harm, permanent disability, death of
>
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HIPAA client
- Patient outcomes
• privacy rule - requires that nurses protect all written and
verbal communication about clients • outcome indicators - changes in persons
health that occur due to intervention
- only team members responsible for care can access, >
- scientific literature
clients have right to obtain copy
• peer reviewed, published research articles -
- password protected, cannot disclosese to unauthorized examined prior by panel of experts for
family members accuracy, authenticity, scientific rigor
- quality improvement - advance practice of healthcare with -
nursing process (AAPIE)
objective, measurable info • assessment, analysis, planning,
implementation, evaluation
