Informatics and Documentation
I. Introduction
a. Documentation is a key communication strategy between health care professionals
and a vital element of nursing practice.
b. Documentation is anything written or printed within a patient record, which may be
either paper, electronic, or a combination of both formats.
c. The information communicated by nurses regarding their patients’ care reflects the
quality of care and accountability for care provided and provides accountability for
the care provided by each member of the health care team.
d. It is necessary to document all the nursing care you provide for each patient,
including assessment data, interventions, and patient responses in the medical record.
e. You are held accountable for the accuracy of the documentation you enter into the
patient’s record.
f. Accreditation agencies such as The Joint Commission specify guidelines for
documentation.
g. Nurses need to follow basic principles to maintain confidentiality during the
transmittal of patient information via verbal, written, or electronic media formats.
II. Health Care Informatics
a. The “application of computer and information science in all basic and biomedical
sciences to facilitate the acquisition, processing, interpretation, optimal use, and
communication of health-related data. The focus is the patient and the process of care
and the goal is to enhance the quality and efficiency of care provided.”
b. Health care information system (HIS)
i. The group of systems used within the health care organization to support and enhance
_______________________________________________________________
health care. It has two major systems called a clinical information system (CIS), and
_______________________________________________________________
administrative information system. Together, the make entry and communication of data
and information more efficient. Administrative information includes databases such as
_______________________________________________________________
payroll, financial, and quality assurance systems.
c. Clinical information system (CIS)
i. includes monitoring systems; order entry systems; and laboratory, radiology,
and pharmacy systems. Examples:
, 1. An order-entry system is a computer program that allows nurses to
order supplies and services from another department, such as sterile
supplies from the central supply department.
2. Computerized provider order entry (CPOE) system allows health care
providers to directly enter orders for patient care into the medical
record from any computer in the hospital information system.
d. Nursing information systems
i. The use of information and computer technology to support all aspects of
nursing practice, including direct delivery of care, administration, education,
and research
ii. Clinical decision support systems (CDSSs)
1. Computerized programs used within the health care setting, to aid and
support clinical decision making
2. CDSSs improve nursing care
3. The knowledge base within a CDSS contains rules and logic
statements that link information required for clinical decisions in order
to generate tailored recommendations for individual patients which are
presented to healthcare providers as alerts, warnings, or other
information for consideration.
I. Introduction
a. Documentation is a key communication strategy between health care professionals
and a vital element of nursing practice.
b. Documentation is anything written or printed within a patient record, which may be
either paper, electronic, or a combination of both formats.
c. The information communicated by nurses regarding their patients’ care reflects the
quality of care and accountability for care provided and provides accountability for
the care provided by each member of the health care team.
d. It is necessary to document all the nursing care you provide for each patient,
including assessment data, interventions, and patient responses in the medical record.
e. You are held accountable for the accuracy of the documentation you enter into the
patient’s record.
f. Accreditation agencies such as The Joint Commission specify guidelines for
documentation.
g. Nurses need to follow basic principles to maintain confidentiality during the
transmittal of patient information via verbal, written, or electronic media formats.
II. Health Care Informatics
a. The “application of computer and information science in all basic and biomedical
sciences to facilitate the acquisition, processing, interpretation, optimal use, and
communication of health-related data. The focus is the patient and the process of care
and the goal is to enhance the quality and efficiency of care provided.”
b. Health care information system (HIS)
i. The group of systems used within the health care organization to support and enhance
_______________________________________________________________
health care. It has two major systems called a clinical information system (CIS), and
_______________________________________________________________
administrative information system. Together, the make entry and communication of data
and information more efficient. Administrative information includes databases such as
_______________________________________________________________
payroll, financial, and quality assurance systems.
c. Clinical information system (CIS)
i. includes monitoring systems; order entry systems; and laboratory, radiology,
and pharmacy systems. Examples:
, 1. An order-entry system is a computer program that allows nurses to
order supplies and services from another department, such as sterile
supplies from the central supply department.
2. Computerized provider order entry (CPOE) system allows health care
providers to directly enter orders for patient care into the medical
record from any computer in the hospital information system.
d. Nursing information systems
i. The use of information and computer technology to support all aspects of
nursing practice, including direct delivery of care, administration, education,
and research
ii. Clinical decision support systems (CDSSs)
1. Computerized programs used within the health care setting, to aid and
support clinical decision making
2. CDSSs improve nursing care
3. The knowledge base within a CDSS contains rules and logic
statements that link information required for clinical decisions in order
to generate tailored recommendations for individual patients which are
presented to healthcare providers as alerts, warnings, or other
information for consideration.
