all right so as you guys can see we're going to focus on informatics and documentation in this module um you might notice i wrote communication down below i know we've already covered communication in a different module um but it really ties very closely with informatics and documentation and the whole quality of patient care really depends on your ability to communicate with other members of the healthcare team and our informatics systems is how we're able to do that when a plan isn't communicated to all members of the health care team care becomes really fragmented and tasks risk being repeated or omitted sometimes there's delays and so that communication becomes really really important i was looking through your ati book and in your ati book it talks about how the chart or the medical record is the legal record of care and emphasizes the fact that it's permanent confidential and admissible in court and i'll highlight that a few times as we move through here and only healthcare providers who are involved directly with the patient's care may access that record and we'll talk about that a little bit more as well when we're looking at what exactly is documentation it's anything that's written or printed on which you rely as a record of proof of patient actions and activities so it as documentation goes it constitutes a fundamental tenant of nursing it's very often said in nursing if it wasn't documented it wasn't done and that just reflects the importance of making a record of what you have done the information that we communicate as nurses regarding a patient's care reflects the quality of care and it gives us accountability for the care that we have provided additionally accreditation agencies such as joint commission they have specific guidelines for what we need to document and then your facility that you work for will also have or where you have your clinical will also have specific guidelines so as nurses we need to follow the basic principles that i'll cover here in this module for you but also know what is specifically required in your institution and then also be very conscientious of maintaining confidentiality about your information whether it's verbal written or in electronic media forms all right so i know that was a lot to throw at you before we even get started but just some basics i wanted you guys to be aware of the next slide as usual um has the objectives and again you're capable of reading those on your own but by the end of this module you should be able to easily address any of those objectives so i'm going to start where your book starts which is basically what is the purpose of the medical record so obviously it's a valuable source of data for all members of the health care team because everyone can access it it can serve a lot of purposes so it can it provides a way for members of the inter-professional team to communicate about the client whether it's the client's needs or their response to treatment or the clinical decision-making process consults outcomes of consults client education discharge planning all the things that healthcare team members are responsible for doing they are responsible for documenting so that it can be communicated that that was done um your potter and perry in the interprofessional communication within the healthcare records section has a really detailed list of information that should be included in a health record including things like the patient identifiers and the nursing diagnosis and all of that and we'll go through some of that a little bit more in detail as we move through um all right and so when we're looking again at that interpersonal um communication within the in the medical records sorry um the legal responsibilities both your potter and perry and your ati have very good guidelines for that and we'll discuss it in class too but there are legal responsibilities things that we as nurses must be um cognizant of when we are in the medical record when we're documenting the medical record just quick highlights accurate documentation is absolutely the best defense in legal claims so that becomes really important you also must follow your organizational standards and you should use really clear descriptions of the care provided in the assessments made and then any mistakes in documentation can result in malpractice and you can there's a table in your book that you can look at that kind of highlights that for you when we move into reimbursement your book does a nice job of talking about the drgs with that they look at the severity of illness the intensity of services provided the quality of care provided all of that is used to determine payment and reimbursement and then for auditing and monitoring quality care again depends on all members of the team being able to effectively communicate so we also have to audit and monitor the charts to make sure that they are being used for that purpose additionally joint commission and cms require organizations to audit and monitor um quality and the appropriateness of care and they also do the same when they come for their surveys and then we use that auditing and wandering as well to identify areas for import for improvement and when we talk about education then there's many different levels for that but for you guys as students reading the chart helps you to learn about the patient and their condition and it helps you to identify trends and patterns and build clinical knowledge so it becomes really important for your education but we also use it in care conferences and we use a lot of the charts for research which is the next bullet point that is there if we do that we have to make sure the information is de-identified meaning anything that could identify that patient has been removed from it we might do some statistical analysis and we might use this information to contribute to evidence-based practice down the road your book refers to a shift electronic documentation um you know we pretty much have shifted to electronic documentation however there is still some paper documentation that sometimes is used the whole shift kind of became began with the american recovery and reinvestment act which in 2009 said that electronic medical records should be in use almost universally by 2014 and we didn't get there quite by 2014 but i would say now that is pretty much the case with some very minor um exceptions and there's some reimbursement issues with that so that's kind of what spurred everybody along was part of that arra was that if you didn't have electronic documentation you were not eligible for the same reimbursements as facilities that did so people got in line pretty quick um some of the advantages to having electronic documentation is that the information is always available um it's available remotely in some cases so a physician can remote into a patient's chart from home which if it was a paper chart obviously wouldn't be able to be done um there's also the ability for multiple providers to access the chart at the same time whereas if it's a paper chart making a picture a book only one person can have the book at the same time um so there is the opportunity for more people to be looking at the same thing at the same time and then the other piece which i can tell you from having worked with paper charts and electronic charts is the ability to integrate information all into one record um so just something that you wouldn't even think about now because it's so commonplace but x-rays x-rays used to be completely separate from the patient's chart because they were basically big you know negatives um that we had separate rooms so i remember in in one of the icus i worked in we had an x-ray reading room across the hall from the icu and that's where we would put the x-rays and that's where we would go and read them and that's where the physicians would go and read them if you walk by there now it's a reflection quiet room because we don't need an x-ray reading room anymore because those x-rays are visible in the chart all you do is click on the tab that says radiology and boof there is the x-ray right there so that certainly is an advantage as well another advantage from the hospital perspective is that access can be tracked so with a paper chart you can't really see who has looked at the chart with an electronic chart you with a lot of certainty can see who has had access to that chart you can't see who's looking over somebody's shoulder but you certainly can see who has had the access and then it's your responsibility to make sure no one's looking over your shoulder and then you're easily able to review previous site visits um so several of our institutions like if you look at kaiser they have charts you can see if you were seen in you know west covina or you were seen in north hollywood and you're then seen in irvine we can see all of those visits we don't need to gather together all those physical charts and that's the same that the va system has and some of our other systems have that too they don't all integrate so if you're seen in a providence system and you then are seen in a kaiser system there might not be the same amount of ability to see that but if you're seen within your own system at least that is visible um and then finally really importantly is legibility i you guys have probably seen the jokes about physician writing um being illegible a lot of times it is and so is nurse writing quite honestly um so when you're documenting electronically that's not an option there's not a sloppy font that you can hit that makes it hard for people to read what you're writing some of the disadvantages to the electronic medical record is that it can be hacked and that's a really high risk and that has happened to some um health care systems and they've received huge fines um for something that isn't really their fault i mean it could happen to anybody um but there are really big sign fines that are associated with that and then obviously there's easy access for nosy staff so it's very easy to very discreetly access something on the computer but like i said access can be tracked so that can be figured out and then visitors of course if you leave your screen open if you're not paying attention to who's standing behind you um then certainly you can sneak a peek at stuff that you don't have any business sneaking a peek at as a visitor um so there definitely are both advantages and disadvantages with that i think that leads very well into maintaining confidentiality and security we as nurses are legally and ethically obligated to keep all client information confidential hipaa includes a privacy rule that requires us as nurses to protect all of that information access to patient records is limited to only those individuals who are involved in the care of the patient and breach of confidentiality comes with really severe consequences nurses are not allowed to discuss the patient's examinations assessments observation diagnosis treatment any of that with someone who's not directly involved in the patient's care you've probably heard countless times about famous people going into the hospital and people leaking information it has happened over and over and over and over um since you know long before i was a nurse i'm sure most recently i think we saw it with britney spears when she was in the hospital we saw it with jesse smallett and we'll see it 20 times again in the next few years because people just don't seem to learn that lesson that everybody has the right to privacy of their medical records as students you have to be really cognizant of how you collect and transport patient data so you need to make sure that you de-identify and again that is not having any patient identifiers on the paperwork including date of birth social security number room number medical record number and if don't print anything if someone hands you something that is printed out don't you know act like it's a hot potato but shred it before you leave the facility don't fold it up and put it in your pocket don't stick it in your textbook i'll share with you guys an example of how that went wrong for somebody so really really be very conscious of that you have the right to review your patient's medical record only for the information that you need to provide safe and effective care u.s students have a little bit more leeway because you may need to view several charts to select appropriate patients to care for and that's okay just stay on the unit that you're on don't look at other units as far as standards go i'll go through some basic ones here but it's really important that you also know what the organization's standards are so current documentation standards require that each patient has a has an assessment and that assessment is documented um here on this slider listed some of the things that might be included in that um there are many different organizations that set standards both federal and state for how we go ahead and document you'll see this factual accurate appropriate abbreviations current organized and complete several times both in your book and on these slides because it really that is how we need to communicate this information so potter and perry covers each of these um in the guidelines for quality documentation section but really you want to make sure factual it's objective it's clear there's no you don't say it appears or it seems that's your interpretation and then accurate you're using exact numbers measurements a 5 centimeter incision no redness or swelling or drainage versus large incision healing well you want to make sure that it is an op accurate description of the results of direct observations and measurements so things like blood pressure 80 over 50 50 patient diaphoretic heart rate 102 regular versus patient doing well uh and then patient statements are subjective so when you're recording subjective data document the patient's exact words within quotation marks kind of like we talked about when we talked about um community i think we talked about the communication section um so example when the patient states i feel nervous but i feel nervous in the parentheses not patient appears nervous and then abbreviations potter and perry has a list i believe ati does well as well of do not use abbreviations we'll talk about that a little bit in class one of the main ones for you guys is no trailing zeros um and leading zeros so make sure that you know what is appropriate to use there and then current just really means that the entry should be timely and then organized means that you should be clear into the point and it should make sense in the order that you are writing it we'll talk a little bit about um the the dar documentation that we can do that helps us do that and then of course it should be complete we don't want to incomplete records for our patients all right and then again moving through the legal guidelines ati had a really nice section on this and i pulled some stuff from there and some stuff from potter and perry as well obviously your books have a little bit more um detail but here are some highlights for you as far as what is important i'm not going to read all of this to you because you can read that on your own but just make sure that you are aware of these if any of these don't make sense to you then please write a note about that and bring that with you to class so that i can explain to you why that is the way that it is um let's see here all right we're going to move into again showing you the factual accurate appropriate complete current organized complete there twice oh fun fun times um clearly want you to be complete on that and then i put a clock up here that has military time because most of our healthcare agencies i haven't been in a facility that doesn't use military time in ages that's how they communicate times that there's no confusion about was it two o'clock two a.m or two o'clock two pm um so if you haven't already set your you know your watch your phone whatever you use your car walk you know your car clock to military time i would encourage you to do that because it's a quick and easy way to get used to this there's a calculation that you can do as well but if you just get used to it in your mind it's a whole lot easier than having to calculate every single time you want to say something that involves a time as far as methods of documentation i'm going to show you a lot of examples in class right now the two that i want to focus on for you are you know the old school paper record and the electronic health record most of the phys all the facilities that you're going to go into use an electronic health record which of course is that digital version of the patient's chart that has all the features that i talked about however they all have a paper system as well so if the electronic system goes down if the computer gets hacked if we have a massive disaster we're going to use that paper documentation because we can't just say well the computer wasn't working so i don't really know what happened to the patient for the last four hours all those same forms that we have electronic we have on paper and those are a lot of the ones that i'm going to bring into class to show to you because obviously i can't bring a live computer system in to show you but i can show you our downtime forms so you have a little bit of an idea of what that looks like here is an example of an electronic medical record there's a couple different ones in your book as well one of them is from a simulation program but what i want you to gather from it is just you know use this is just one page that you are looking at but you can click on different things to get to see yesterday and to get see the physician orders and to get to see the medication so once you get into your clinical site you'll get really familiar with what it is you need to click on to get the information that you need when we look at the different methods of documentation so both in your skills lab and in clinical you will more than likely be using checkbox for your assessment findings so as you go through and you do an assessment on your patient you're going to it's going to have a section if you're doing a cardiac assessment it's going to have a section and it's going to say s1 and you're going to click normal not normal s2 normal not normal heart rate you're going to click in you know what it is that your specific patient's heart rate is what do what does their heart sound like what does the lungs sound like um and then anything that you can't do with your checkboxes is something that you're going to write a narrative note for um charting by exception is a little bit tricky and some of our facilities do this so they have a term that is within defined limits you cannot however use that term and potter and perry does a nice job of explaining this as well you can't use that term unless your facility has defined what within defined limits means or within normal limits so it'll be wdl or wnl there may be some other abbreviations for it as well so they have to be specific and there's usually a section at the very top that says within defined limits equals and then it'll say like for cardiac it'll say normal s1 and s2 heart rate between 100 and between 80 and 100 and regular denies chest pain so on and so forth so if any of those are not found then you can't select within normal limits because it was not what is defined as normal limits all those things have to be there for it to be within normal limits so in that case then you would have to probably do a narrative note in addition and then here it shows the different forms of narrative notes and we'll go into this in a little bit more detail um as well sorry i just realized i'm blocking some of your view there okay um so there is a lot of variety of different types of um of these narrative notes so your health assessment book i think uses soap and soapy quite a bit some of the other options are pi a i o d a r if you look at the bottom three if you look at pi a i o and d a r you can see that essentially they're the same thing they're a way of organizing what is the assessment data problem that you found what did you do about it and what was the outcome or the patient's response at the end of that so for example we used to use the aio documentation in skills lab and we just recently switched to using dar charting the only thing that really changed was that instead of writing a you wrote d instead of writing i you wrote a and instead of writing o you write r because assessment and data are essentially the same thing action and intervention are essentially the same thing and outcome and response are essentially the same thing and if you look at the soap and soapy it really is the same thing so you just have subjective and objective broken apart wherein these other systems those are all included in that first step the p the a or the d hopefully that makes sense to you guys i was not trying to confuse you so if you have questions about that make sure that you let me know then some of the things that you need to know that are available in your patients chart um so there's always going to be an admission form a history form there's going to be lots of flow sheets and graphic records there will be a patient care summary care plans discharge summary forms so no matter what system you're in even if it looks very unfamiliar so you spent an entire you know semester where you were using one type of system and then you end up using a different system when you go to a different hospital the same things are in the chart so just kind of take a moment to think about what would they call it and where would it be the graphic and flow sheet isn't really discussed much in your potter and parry but that's a really good visual source of data so it helps kind of identify trends so if you're just looking at a list of somebody writing blood pressure numbers it's not the same as looking at a graph where you can see wow it's actually gradually decreasing and the heart rate is gradually going up uh oh that's a problem versus just looking at the numbers you might not notice that as quickly the patient care summary is really good for report and this is the thing that a lot of nurses will print out for you but just make sure that you don't take it home it has just kind of all the patient's information you know as a snippet in one page um the care plans that you do in um in clinical are computerized so they're kind of that check box documentation as well but they follow the same format of the care plans that we talk about in here and in clinical and then the discharge planning that starts from the minute the patient is admitted and we have to include documentation of all the patients education and the resources that are provided so that's a really important component as well and then moving into that dar documentation that i told you we would get a little bit more detail of so when you start with the d again this is the data that you are collecting this is the situation what is going on why does the patient need whatever it is that you're going to do to them the um a is that nursing intervention the action so what did you do for the patient what happened throughout that procedure and then the r is the response of the patient how is the patient now have you reevaluated followed up so for an example if you were inserting a nasogastric tube so a tube down the patient's nose into their stomach your d may include something like patient complains of severe nausea abdomen distended patient states and quotation marks i feel terrible abdominal discomfort rated eight out of ten described sensation of fullness whatever that looks like that's the information that you've gathered before doing anything to your patient your a then maybe order for ng tube obtained ng placed via right nostril taped at 55 centimeters 600 milliliters of dark green drainage returned ng2 placed low continuous suction so whatever it is that you did and then that r would be patient tolerated the procedure well abdominal distension is decreased patient no longer complains of nausea or discomfort so usually the r involves reassessing what you assessed in the d because you are now seeing what is the response they were complaining about something the data that you had was data that told you how to do something so now you want to evaluate to see if what you did was effective and what i want you to notice from this is just how very factual and patient centered it is so again it's not nurse centered it's not your diary so it's not you know i placed an or i placed an ng tube down and i help the patient with this it's about what happened to the patient and that becomes really important in our documentation as well some other documentation communication that we have we have our hand-off reports so we covered espar when we did communication but if you find that a patient breathes easier when they're in a certain position than that you relay that information to the next nurse caring for the patient we want to make sure with our telephone reports and orders as a student you won't be doing this you're not allowed to receive orders from a physician you may be involved in the communication later on in the program but you cannot write down an order from a physician but you want to make sure that you use sbar to relay the information and you want to make sure that you document even if no orders were obtained this protects you because clearly you thought action was needed because you've contacted a provider so you want to make sure that you say that you did contact this provider and that no orders were received and if you do receive orders then make sure that you um read back all those orders and that you document that read back you also want to make sure to time and date and write the orders with that t.o or telephone order or vo verbal order and then the read back so it can again be the t-o-r-b t-o read back however you want to do that to get the point across that it was a telephone order or a verbal order and that it had that read back part you're then going to include your name and credentials the name of the physician and then it must be co-signed or acknowledged by the physician or provider within 24 hours so that's kind of a lot to hang on to and we'll go over that in class a little bit more but that's all really important information for you to have as far as incident or recurrence reports these are used to document any event that's not consistent with routine expected care or standard policies and procedures so it can help to identify systems or human issues that need to be addressed to reduce the risk of harm in the future and it's not part of the patient's permanent record it should not be referred to in the patient's chart it's used internally for process improvement quality improvement safety that type of thing potter and perry also covers a few things that i'm not going to cover here it talks about acuity rating systems long-term care documentation home health documentation case management i want you guys to read through those just to get a better understanding over all of the different types of communication that nurses can be involved in but it's not really immediately applicable because you're not a case manager and you're not going to be doing home health next you know as part of your clinical and you're not working in a long-term care facility so it's not test material or something that you can immediately put to work but it is important for you to have an idea of that all right so i'm going to move into some electronic medical record basics so kind of as i said before analysts can retrace every state step you take within the patient's record so anywhere you go in that chart somebody if they want to can do a deep dive and find out that you were there you could always correct your mistakes but the original entry again if they do a deep dive will still be there which isn't a problem if you legitimately made a mistake and covered it up but if you tried to delete a bunch of things because you noticed something was wrong with your patient but you didn't do anything about it and you thought oh i'm just going to pretend i didn't notice and you're going to delete that stuff somebody can see that you deleted that and that would be a bigger problem for you than your original problem make sure that you're only assessing the patients whom you are caring for or assisting to provide care for make sure you log off that's a really huge issue so make and especially as students we're visitors so make sure that we um you know use the systems appropriately the way they're intended to and part of that is we want to make sure information we have access to is not accessible to somebody who shouldn't have it and then do not share your password ever that is very very very bad practice um and as a student a hundred percent we do not want you engaging in that so even if it's the nurse you're working with who says oh i can't get in i'm going to do this under your password no because then it looks like you did something that only a nurse could do and that's a huge problem for you so get your instructor and say i'm really not comfortable my instructor will not want me doing that let me get my instructor that's the backup that you go to the next couple slides is going to include something that is not in your book there is an article posted on blackboard uh okay i'm just sorry um about that um so this is hourly rounding so this is the article that talked about the importance of um nurses making sure they have a systematic proactive nurse driven process to anticipate and address the needs of their patients and most of these systems use the three p's um they don't always call it the three ps sometimes they use words that are a little more classed up than pain potty and position but essentially those are the things they are looking at we're going to look at our patients comfort level we're going to look at their toileting we're going to look at their skin and their positioning and then you can see there's the other p's here that are associated with that article there for me i think the periphery is the one that encompasses everything so if i'm looking at the patient's periphery i'm also looking at their pumps i'm also looking at their possessions i'm also looking at what is the plan for this pay for for this patient um and then as i part i will you know say my parting words with the patient so i think that one kind of encompasses a lot of them um some hospitals will use periphery some will use um pumps some will use again so a variety of that use whatever your facility insists that you use but then you can also use whatever is helpful to you so you may only document pain potty and position but if you think that that periphery and parting a really important part to include in your round then include it in your round it's just not going to be part of what you are required um to do and document the next slide is a little bit fuzzy i took it from an in-service that i went to with permission to talk about again the hourly rounding and what the expectations are so you can see the expectation is again it's kind of an organized way of doing things so you know use some opening words to introduce yourself talk about why you're there perform the skills that you need to do address those three p's um you know look at their comfort look at the environment have some closing words that the patient knows okay you're leaving now explain to them when you'll be back and then make sure that this gets documented um it's usually documented in the emr on the hour not at the precise time that you did it so you don't need to say at 803 i did my hourly rounds at 904 i did my hourly rounds at 1002 it's 8 9 10 unless there's a huge discrepancy so you know maybe a 15 minute round but you don't need to be super specific with the minutes exactly i'll cover that a little bit more on this next documentation with hourly rounding slides um so can i wait and document all the visits at once yes if that's your only option um you can and you can backdate it and say okay i did this at 10 and this is 11 and this at 12. however best practice is to document it right as you are there um because then you don't you don't get tied up and nothing else happens the worst thing that could happen is that you did all of your hourly rounds on all your patients everything's completely under control and at noon you decide you're going to go to lunch you give report to somebody else who takes care of your patient and when you come back at 12 30 you hear that your patient had a fall you know you checked on your patient at noon before you went to lunch and everything was the way it was supposed to be they had their call light they had all the things that they needed but in that document it looks like no one has checked on that patient since the night nurse did it at six am that's a problem for you and you can go back and put those in and you can you know verify yes i did that but it still doesn't look as good as if you had documented each of those as they happened then it's a hundred percent indisputable that you had done it um as far as changing times on the documentation like i said yes you can go back in and say i did this at eight o'clock this at nine o'clock this at ten o'clock but each of those is going to show up as being documented at 12 45 when your patient fell at 12 30. so there's again if you do a deep dive you'll see the actual time what's going to show up on a glance is the time that you tell it to show should you document in a patient's room i say yes because again it's a moment with that patient some of our hospitals are set up so that your back is to the patient so if you look at the system down in the corner here i can only imagine that the patient is kind of like looking at the back of the nurse which is kind of annoying um but it's still a moment with your nurse and they you can still look over at the patient ask them if they have any more questions before you go and it just gives them a little bit more you know slowed down a little bit so if they come up with their questions they can do that um when i have the two glove or not glove here what i'm talking about is in a patient who is not on isolation so a standard precautions patients you should not be using gloves on that patient's computer because gloves are intended for your patient care um so if you're using gloves on the computer did you first do your patient care and then take your sloppy dirty gloves and put them on the computer and now somebody else is going to come along and follow the rules not wearing gloves and put their hands on the computer if you are in an isolation room that requires you to wear gloves then of course you should be wearing gloves on the computer because you're required to wear gloves in the room so that is a yes and no answer to that one um and then i gave you guys the question of how do you document or can you document hourly rounds on or an hourly check on a sleeping patient yes absolutely you can um most facilities have implemented hourly rounding schedules that are you know from 6 00 am to 10 pm you're going to go every hour and then overnight it's gonna be every two hours um and you don't have to wake the patient up for that you there's a you know you there's a check box that you can check for you know they were sleeping um but however if it's somebody who's not capable of remembering that they need to get up and go to the restroom that type of thing then maybe every check or every other check you should wake them up and ask them if they need to go um and if it's somebody who's incontinent then obviously you need to check them for that um so some exceptions to that but you don't have to wake somebody up every hour to do an hourly check that's that's kind of counterproductive all right we're going to look a little bit now at the general concept of health informatics so health informatics um really is the application of computer and information science that helps us manage health related data and it focuses on the patient and the process of care and we as nurses have a really big role within this as well so we can help develop these systems we can make recommendations for how we should update these systems change these systems and really our entire goal is just to enhance the quality and efficiency of the care provided the health information technology economic clinical health act wow that is a mouthful was a big driver for a lot of these updates that we have the government offers incentives i think i mentioned this at the beginning of the lecture and payments to health care agencies and providers to adopt the ehrs and so again now that's pretty much the case everywhere there are some penalties that can be assessed to health care facilities that don't adopt ehrs however i don't know if many that haven't some of them are pretty weak systems but they do have them in place and that goes back to again the two different laws that i had told you guys about so the hitech as well um when we're looking at clinical information systems there's both the cis and the cpoe so the cis is really used this is where any of the data that you are accessing so the clinical information system is where you're going to find your patient data so things like your vital signs assessments orders notes labs all of that stuff and you're inputting that information in there as well right you take a set of vital signs you document a set of vital signs the cpoe is where the healthcare provider can directly enter their orders um and by doing so we omit the step of the verbal order the telephone order so this improves accuracy it improves speed it improves productivity hopefully it saves money as well it's legible there's some standardization around it so there's a lot of advantages um to that and the order entry systems they allow the nurses to to order supplies and services from other departments so there's different tabs that we can use that can communicate with pharmacy with dietary so those are those are really important and then like i said the direct order entry eliminates a lot of the issues um that we had with either verbal orders telephone orders or illegible writing any of that was kind of avoided with this uh the next slide here is a little bit funny looking i tried to put up an actual clinical decision uh support system uh infographic and it was just so confusing i thought it would absolutely just confuse you guys to no end and not really be useful to you um so what i'm intending with this graph that i created right here is just to show you that the cds is intended to improve quality care to avoid errors and adverse events to allow the care members to be more efficient so the tools are designed to help sift through enormous amounts of digital data and then they're going to suggest next steps of treatments alert providers to things they may not have seen catch potential problems so it's just simple things such as drug interactions if you enter all your patients medications into your computer which has a clinical decision support system that system is going to sort through that and say hey wait a minute why is that patient on this medication and this medication at the same time those two don't work well together did you know your patient is on both of those versus you having to sit and look at 52 medications and then pull all that information from the back of your brain about which two of those may not play nice together so this is something that is kind of working in the background that you may not even be aware of and you'll see little pop-ups on your screen that is alerting you to different things so very very useful and something that we certainly wouldn't have if we weren't using a digital medium so that's kind of cool then the next thing i'll show you guys and talk about which is also in your book is nursing informatics it is a booming industry there are so many opportunities for nurses we have a graduate from our program who is a peds nurse he also comes back and teaches lab and clinical with us and he was doing i.t stuff before he ever went to nursing school he was actually an undergrad student here at concordia and worked in the i.t department and had always had an interest in that and so as he then became a nurse and you know was working as a nurse he kind of got recruited over to that side again so now he's kind of sharing his time 50 50 of um you know doing patient care but also being involved in informatics being involved in creating new systems for documentation updating systems looking at are the things that we have effective are we communicating in the most clear way that we can so very very interesting specialty it really is able to support the way that nurses function and work so if everything is created by non-nurses it doesn't work the way that nurses want it to work so having some nurses involved in this informatics process is a really big deal an expertly designed um clinical information system is really it's based on nursing informatics and it integrates and supports both clinical judgment and up to up-to-date evidence-based practice and how nurses do what they do so that becomes really important as a nurse you need to know how to use clinical databases within your institution you need to know how to apply the information so you can deliver you know that high quality appropriate patient care and as students you have that same responsibility as well some of the advantages of nursing information systems it should allow you to spend more time with your patients because you should be able to be more efficient in finding the information you need and documenting the information that you need you should have better access to information because as i said you are able to see information at the same time somebody else's you don't have to wait to get a physical chart it should enhance the quality of documentation because again it's legible it's quicker most of us can type quicker than we can write it hopefully will reduce the errors in omission reduce hospital costs because we're better able to capture all the things that we did do for the patient um initially when we rolled out computer documentation and um nursing information systems i'm going to say it did not increase nurse job satisfaction it stressed people out a ton but as people have gotten used to working with these systems now it stresses people out when the system's not working so if you've ever been in a facility when there's a down time which is when the computer is not working people are flustered that's kind of what they look like in reverse when we first started with all of this because they were used to what they were used to and now all of a sudden we're telling them they got to click 17 different places when all they had to do was turn three pages before um so you can certainly see the frustration with that it makes it really easy to comply with the crediting agencies because we can pull information so if they want to see a certain thing you can pull that from the chart really easily with your digital algorithms instead of having to flip through tons of pages and then also it really helps us with our database development and our research of being able to you know pull statistics out of the charts um all right i think i said enough about that all right so i'm going to go just a little bit more into some of the details um that are in your book as well so it talks about privacy and confidentiality and the security mechanisms and absolutely computerized documentation has legal risk um it is possible for anyone to access a computer station within a health care agency and gain information about any patient if we don't use the processes that we have to protect information such as logging off most security mechanisms for information systems use a combination of logical and physical restrictions to protect that information to protect patient privacy the health care agencies again they track whoever is accessing that patient's record when we are printing and faxing information is really when it is most high risk for unauthorized release of information because we can accidentally fax it to someone who shouldn't have it or we could accidentally leave what we have printed laying around that was my dog bless you all papers that contain patient information should be destroyed when no longer needed or in your case shredded before you leave the facility nurses uh may be responsible for erasing files um you know doing that type of thing you are not responsible for erasing anything in the computer that would be after you have rn after your name but at least make sure that what you print out or has been printed out for you is shredded and then make sure that you follow the disposal policy for records in your institution there's usually certain bins that are the shredder bins so it's not enough to just rip it in four pieces and throw it in the trash can it has to go into the proper disposal bit um and then when we talk again about the i think i talked about most about the protection of the confidentiality obviously the facilities have firewalls um setups to try and prevent hacking or unnecessary access to information um but as i said it is a disadvantage that we can't always be certain of that all right last slide here this is just some of the key points from the back of your book um there are many more so please just like you do for every other chapter go back and read the key points and make sure that you understand what is going on with those um so definitely again communication is tied to the content that we have here and in this case it's that interprofessional communication everyone can see what the physician has seen everyone can see what the nurse has seen the dietitian the physical therapist that's a really big deal again i go over that quality documentation that it has to be factual accurate appropriate abbreviations and complete twice i don't know why i have that there twice but apparently i really want you to be complete and then nursing documentation really is essential right it communicates the care that's been provided it communicates the patient's response it serves as a legal record of the care which will limit your liability if you did things appropriately and it also helps support reimbursement which if your facility doesn't get reimbursement they don't have money to pay you for the services that you're rendering so that does become important on a level to you and then of course we have to restrict access we have to monitor access and then you as nursing students have to develop the knowledge skills and attitude um that enable you to use the information technology so if you're somebody who came into the program saying you know i'm not techy i'm not really good at all that stuff that's too bad you need to get good at that you need to not be afraid to go into a patient's chart not afraid to push a button to see where you can go the systems are set up you can't accidentally delete the patient's entire record that would be very very very difficult to do and take steps that you don't have access to so as you're in clinical make sure that you are looking through that chart and seeing what do you have access to because as a student you need to know the patient's lab you need to know the uh medications you need to know their history and so only by being competent to use the information technology that they use at that facility are you capable of that all right that is about all that i have for you guys in this module please make sure you write down your questions and um let me know what i can do to help clarify any of this all right thank you