WGU D221 Practice Improvement Plan Proposal
Audit Trails
Software that is used for
detecting security violations,
performance problems, &
flaws. Records activity by
users & system. **Goal is to
improve data integrity. An
audit trail must contain the
name of the user, the
application triggering the
audit, the workstation, the
specific document, a
description of event being
audited, & the date/time to
determine integrity of data.
Benchmark
Continual process of
measuring services &
practices against the toughest
competitors in the healthcare
industry. Comparing the
performance of an
organization or clinician to
others.
Clinical Decision Support System (CDSS)
Supports healthcare
practitioners in making pt-
care decisions by integrating
pt data w/ current clinical
knowledge. Provides
recommendations for care &
must be balanced w/
professional judgment, not
used in place of it.
1
, WGU D221 Practice Improvement Plan Proposal
Clinical Information System
Software used to access
client data, plan, implement,
& evaluate care. May be
specific to certain
departments: lab, radiology,
pharmacy, or pt populations.
Provides pt centric decision-
making functionality to help
guide a RN w/ decision-
making. Acquires pt data so
that healthcare pros can
review it & use information
to deliver care.
Confidentiality
Unspoken understanding that
private information shared in
a situation, in which a
relationship has been
established for the purpose
of treatment or delivery of
services will remain
protected.
Consolidated
Clinical Document
Architecture (C-CDA)
Allows interoperability of
health information exchange
between hospital systems.
Continuity of Care Record (CCD)
Snapshot of a pt's health &
healthcare to provider who
does not have access to the
person's EHR.
Data Analysis
The processing of data that
identify trends & patterns of
relationships.
2
, WGU D221 Practice Improvement Plan Proposal
Data Integrity
Ability to collect, store,
retrieve correct, complete, &
current data so that the data
are available to authorized
users when needed. Can be
compromised by incorrect
entry of information, data
tampering, & system failure.
Prevention by implementing
security measures, audit
trails, & having detailed
policies & procedures. Data
integrity is the state wherein
data are uncorrupted,
accurate, & valid.
Data Mining
Technique that look for
hidden patterns &
relationships in large groups
of data using software.
3
, WGU D221 Practice Improvement Plan Proposal
Decision Support Tool / Clinician Decision Support (CDS)
/ Decision Support System/Software (DDS)
Software/app to help in
human decision process.
Software will look at the pt's
data & suggest appropriate
medical/nursing
interventions. Can also
trigger prompts/alerts to user.
Requires human user input.
Decreases pt safety risk &
increases positive pt
outcomes (alerts for
abnormal vs, lab results, med
contraindication, etc.) The
right components of a CDS
include a trigger, such as
med order; input data, such
as lab values; intervention
info, such as other options
provided; & action step, such
as action selected by the Dr.
4
Audit Trails
Software that is used for
detecting security violations,
performance problems, &
flaws. Records activity by
users & system. **Goal is to
improve data integrity. An
audit trail must contain the
name of the user, the
application triggering the
audit, the workstation, the
specific document, a
description of event being
audited, & the date/time to
determine integrity of data.
Benchmark
Continual process of
measuring services &
practices against the toughest
competitors in the healthcare
industry. Comparing the
performance of an
organization or clinician to
others.
Clinical Decision Support System (CDSS)
Supports healthcare
practitioners in making pt-
care decisions by integrating
pt data w/ current clinical
knowledge. Provides
recommendations for care &
must be balanced w/
professional judgment, not
used in place of it.
1
, WGU D221 Practice Improvement Plan Proposal
Clinical Information System
Software used to access
client data, plan, implement,
& evaluate care. May be
specific to certain
departments: lab, radiology,
pharmacy, or pt populations.
Provides pt centric decision-
making functionality to help
guide a RN w/ decision-
making. Acquires pt data so
that healthcare pros can
review it & use information
to deliver care.
Confidentiality
Unspoken understanding that
private information shared in
a situation, in which a
relationship has been
established for the purpose
of treatment or delivery of
services will remain
protected.
Consolidated
Clinical Document
Architecture (C-CDA)
Allows interoperability of
health information exchange
between hospital systems.
Continuity of Care Record (CCD)
Snapshot of a pt's health &
healthcare to provider who
does not have access to the
person's EHR.
Data Analysis
The processing of data that
identify trends & patterns of
relationships.
2
, WGU D221 Practice Improvement Plan Proposal
Data Integrity
Ability to collect, store,
retrieve correct, complete, &
current data so that the data
are available to authorized
users when needed. Can be
compromised by incorrect
entry of information, data
tampering, & system failure.
Prevention by implementing
security measures, audit
trails, & having detailed
policies & procedures. Data
integrity is the state wherein
data are uncorrupted,
accurate, & valid.
Data Mining
Technique that look for
hidden patterns &
relationships in large groups
of data using software.
3
, WGU D221 Practice Improvement Plan Proposal
Decision Support Tool / Clinician Decision Support (CDS)
/ Decision Support System/Software (DDS)
Software/app to help in
human decision process.
Software will look at the pt's
data & suggest appropriate
medical/nursing
interventions. Can also
trigger prompts/alerts to user.
Requires human user input.
Decreases pt safety risk &
increases positive pt
outcomes (alerts for
abnormal vs, lab results, med
contraindication, etc.) The
right components of a CDS
include a trigger, such as
med order; input data, such
as lab values; intervention
info, such as other options
provided; & action step, such
as action selected by the Dr.
4
