NR 361 Week 2 Discussion: Experiences with Healthcare Information Systems
This week's graded discussion topic relates to the following Course Outcomes (CO).
CO3: Define standardized terminology that reflects nursing's unique contribution to
patient outcomes. (PO #3)
CO4: Investigate safeguards and decision-making support tools embedded in
patientcare technologies and information systems to support a safe practice
environment for both…
Share your experiences with healthcare information systems, past or present. Has it been
an easy transition or difficult? Why do you believe your experience has been positive or
negative? If you are currently not working in a healthcare setting, how has the medical
record exposure in nursing school impacted your current knowledge?
Answer:
My experience allowed me access to several healthcare information systems from EMR, EKG,
onsite lab testing devices. There are many moments these items work effectively well and of
course other times they do not. We have moved forward in technology from paper charts to
EMR, this was helpful to better understand the simple things like staff handwriting. EKG devices
went from manual entry and visual interpretation to digital upload and with possible outcome
results on the report. One of the best upgrades in information technologies that have been a great
help for it has allowed us to find out results asap regarding certain lab criteria to allow immediate
treatment of care. Having immediate access to test results has resulted in good outcomes for
example clients heading into surgery we need to know the simplest lab result of H&H and type
and cross. I have received results with a H&H and showed server anemia that it was unsafe for
clients to have elective surgery and have been postpone. The other result for type and cross assist
when we have served blood loss in surgery, we can transfusion and knowing a patient blood type
& cross allows for the correct blood to be administered to save a life.
With all the advancement in technology of healthcare informatics there needs to be standardized
terminology & safeguards in place. EHR can collect and store this information which can be
used to improve quality and safety of care as well as identify best practices vs areas in need of
, improvement (Tastan et al., 2013, p. 1161). Furthermore, the use of standardized nursing
terminology can be used to assess nursing competency. The use of standardized nursing jargons
promises to enhance communication of healthcare nationally and internationally. It will provide
healthcare workers with helpful interventions that may not be in use. Standardized medical
terminology and the usage of structured reporting have been shown to improve the usage of
medical data, such as research, public health, and case studies. According to Tastan et al., (2013),
there are five standard nursing terminology (SNT) set recognized by the American Nurses
Association, (1) NANDA-I (North American Nursing Diagnosis-International),NIC (Nursing
Interventions classification), and NOC (Nursing Outcome Classification) (combined they are
known as NNN), (2) ICNP (International Classification for Nursing Practice), (3) Omaha
System, (4) CCC/HHCC (Clinical Care Classification/Home Health Care Classification) and
(5)PNDS (Perioperative Nursing Data Set) (Tastan et al., 2013, p. 1162). Given the federal
requirements to EHRSs, there is a need to establish standards for the implementation of
terminologies within an EHRS. Healthcare terminology needs to be universally understood
across all healthcare providers and organizations for healthcare systems to be interoperable and
to uniformly exchange data. To accomplish interoperability, standardized clinical terminologies
must be implemented within EHRs (McCormick et al., 2015).
Just like an EHR must have standard terminology for others to be able to understand, this also a
safeguard to ensure everyone understands what is in the patient HER to treat them no matter
where they seek care. The terminology use is a safeguard not just for data collection and
documentation. There are many support technology devices that have their own safeguards
within them. Many supportive devices have safeguards for both patient and caregiver:
Automated IV Pumps - Automated IV pumps control the dosages and drips given to
patients. This ensures the right amount going into the client as ordered.
Wearable Devices – glucose monitoring for continues reading. This allows for client to
not have to puncture their fingers for blood supply for testing which allow clients to
check often and be knowledgeable of their glucose level to accommodate their diet and
medication administration.
There are various tools and technologies which safeguard resources: intrusion detection systems,
passwords, firewalls, antivirus software and encryption, to name a few. Three pillars known for
security safeguard themes for healthcare are administrative safeguards, physical safeguards, and
technical safeguards. They have all provided great supportive assistance in patient care and
outcomes in their quality of health.
References:
This week's graded discussion topic relates to the following Course Outcomes (CO).
CO3: Define standardized terminology that reflects nursing's unique contribution to
patient outcomes. (PO #3)
CO4: Investigate safeguards and decision-making support tools embedded in
patientcare technologies and information systems to support a safe practice
environment for both…
Share your experiences with healthcare information systems, past or present. Has it been
an easy transition or difficult? Why do you believe your experience has been positive or
negative? If you are currently not working in a healthcare setting, how has the medical
record exposure in nursing school impacted your current knowledge?
Answer:
My experience allowed me access to several healthcare information systems from EMR, EKG,
onsite lab testing devices. There are many moments these items work effectively well and of
course other times they do not. We have moved forward in technology from paper charts to
EMR, this was helpful to better understand the simple things like staff handwriting. EKG devices
went from manual entry and visual interpretation to digital upload and with possible outcome
results on the report. One of the best upgrades in information technologies that have been a great
help for it has allowed us to find out results asap regarding certain lab criteria to allow immediate
treatment of care. Having immediate access to test results has resulted in good outcomes for
example clients heading into surgery we need to know the simplest lab result of H&H and type
and cross. I have received results with a H&H and showed server anemia that it was unsafe for
clients to have elective surgery and have been postpone. The other result for type and cross assist
when we have served blood loss in surgery, we can transfusion and knowing a patient blood type
& cross allows for the correct blood to be administered to save a life.
With all the advancement in technology of healthcare informatics there needs to be standardized
terminology & safeguards in place. EHR can collect and store this information which can be
used to improve quality and safety of care as well as identify best practices vs areas in need of
, improvement (Tastan et al., 2013, p. 1161). Furthermore, the use of standardized nursing
terminology can be used to assess nursing competency. The use of standardized nursing jargons
promises to enhance communication of healthcare nationally and internationally. It will provide
healthcare workers with helpful interventions that may not be in use. Standardized medical
terminology and the usage of structured reporting have been shown to improve the usage of
medical data, such as research, public health, and case studies. According to Tastan et al., (2013),
there are five standard nursing terminology (SNT) set recognized by the American Nurses
Association, (1) NANDA-I (North American Nursing Diagnosis-International),NIC (Nursing
Interventions classification), and NOC (Nursing Outcome Classification) (combined they are
known as NNN), (2) ICNP (International Classification for Nursing Practice), (3) Omaha
System, (4) CCC/HHCC (Clinical Care Classification/Home Health Care Classification) and
(5)PNDS (Perioperative Nursing Data Set) (Tastan et al., 2013, p. 1162). Given the federal
requirements to EHRSs, there is a need to establish standards for the implementation of
terminologies within an EHRS. Healthcare terminology needs to be universally understood
across all healthcare providers and organizations for healthcare systems to be interoperable and
to uniformly exchange data. To accomplish interoperability, standardized clinical terminologies
must be implemented within EHRs (McCormick et al., 2015).
Just like an EHR must have standard terminology for others to be able to understand, this also a
safeguard to ensure everyone understands what is in the patient HER to treat them no matter
where they seek care. The terminology use is a safeguard not just for data collection and
documentation. There are many support technology devices that have their own safeguards
within them. Many supportive devices have safeguards for both patient and caregiver:
Automated IV Pumps - Automated IV pumps control the dosages and drips given to
patients. This ensures the right amount going into the client as ordered.
Wearable Devices – glucose monitoring for continues reading. This allows for client to
not have to puncture their fingers for blood supply for testing which allow clients to
check often and be knowledgeable of their glucose level to accommodate their diet and
medication administration.
There are various tools and technologies which safeguard resources: intrusion detection systems,
passwords, firewalls, antivirus software and encryption, to name a few. Three pillars known for
security safeguard themes for healthcare are administrative safeguards, physical safeguards, and
technical safeguards. They have all provided great supportive assistance in patient care and
outcomes in their quality of health.
References:
