1. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 13 Documentation and Informatics

2. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Informatics Clinical information systems Electronic health record Nursing information systems

3. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Documentation as Communication Documentation –Written evidence of: Interactions Administration of tests, therapies, and education Client’s responses

4. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Purposes of Health Care Documentation Communication Education Research Reimbursement (continued)

5. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Purposes of Health Care Documentation Legal and practice standards –HIPAA –Informed consent –Advance directives –ANA standards of care –State nurse practice acts –The Joint Commission

6. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Principles of Effective Documentation Nursing notes must: –Be logical –Be focused –Be relevant to care –Represent each phase of nursing process

7. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Elements of Effective Documentation Use of common vocabulary Legibility Abbreviations and symbols Organization Accuracy Documenting medication error Confidentiality

8. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Methods of Documentation Narrative charting Source-oriented charting Problem-oriented charting PIE charting Focus charting Charting by exception Computerized documentation Case management process

9. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Forms for Recording Data Kardex Flow sheet Nurse’s progress notes Discharge summary

10. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Reporting Summary reports Telephone reports and orders Incident reports

11. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Computers in Nursing Professional nurse as information consumer and producer Informatics competencies for nurses Applications of nursing informatics Telehealth (continued)

12. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Computers in Nursing Evidence-based practice and research Criteria for evaluating validity of information