CRITICAL CARE APPLICATIONS

 CCN- deals with human responses to life threatening problems

 Use of microprocessors in devices
 Bedside monitoring systems
 MIB (Medical Information Bus)-classify backbone of information exchange (data
moved from one point to another)

Information technology in the critical care environment

 Process, store and integrate physiologic and diagnostic information

 Present deviations from preset ranges by alarm/alert
 Accept and store patient care documentation in a lifetime clinical repository
 Trend data in graphical presentation
 Provide clinical decision support alerts, alarms, protocols
 Access to vital pt. info from any location
 Comparatively evaluate pt. for outcome analysis
 Present clinical data based on problem/system

IT APPLICATIONS AND FUNCTIONS IN CRITICAL CARE

1. Mechanical Ventilators

2. Physiologic Monitoring Systems

Example:

 Gather pt. vital signs

 In critical care setting, built to incorporate both arrhythmia hemodynamic
monitoring
 Accuracy of each data is important

Basic components:

 Sensors (ECG electrode)

  Signal conditioners (paper recorder)—amplify or filter display device
 File (storage file, alarm signal)—rank and order information
 Computer processor (paper reports)—analyze data and direct reports
 Evaluation or controlling component (notice on screen, alarm signal)—regulate
equipment or alert the nurse

Telemetry

 Telemetry refers to the automatic measurement and transmission of data at a

distance by radio, cellular or other means.
 Patients are monitored from remote location.
 Patients are mobile/not in bedside
 Uses transmitters and antenna
 Signal loss is a problem

Arrhythmia monitor

 Monitor and analyze cardiac rhythm

 2 types of arrhythmia systems:
 Detection surveillance
 Diagnostic/interpretative

IT APPLICATIONS AND FUNCTIONS IN CRITICAL CARE

3. Critical Care Information Systems

 Collect, store, organize, retrieve and manipulate all data r/'t care of critically ill pt
 Purpose: organize pt's current and historical data for use by all care providers in
pt. care
 Integrate data from bedside devices, ancillary dept, medications, orders, PA
 Incorporate personal computers
Components:

 Patient management—admission, transfer, discharge

 VS monitoring
 Diagnostic testing results
 Clinical documentation
 Decision support
 Medication management
 Interdisciplinary plans of care
 Provider order entry

CHN

 Synthesis of nsg practice and public health practice applied to promoting and
preserving the health of populations (ANA, 1980).
 Focus: population as a whole
 Computer systems targeted toward specific functional needs rather than clinical
care/delivery

Population focused:

 Track immunization rates

 Continuity of care needs
 Billing of services

CHN System Devt

 Used computers since late 1960's. Focused on regulatory compliance, billing and
statistical reporting.
  4 domains of concentrations that directed Management Information Systems
(MIS) for practice:
1. Public health on population and epidemiologic trends
2. Home health
3. Special population ex. mental health
4. Outpatient care preventive care

Home Health

 Home healthcare provision of preventive, therapeutic, restorative and suppotive

healthcare in the home
 Data processing systems designed mostly for billing

Public Health

 Coordinated effort at the local, state and federal levels whose mission is fulfilling
society's interest in assuring conditions in which people can be healthy (Institute
of Medicine/lOM, 2004)

Focus:

1. Prevent, identify, investigate, eliminate community health problems

2. Access to competent personal healthcare services
3. Educate and empower for health behaviors

 Statistical reporting systems for personnel, programs and services

 Used information systems for categorical functions - collect electronic birth and
death data, communicable disease reporting, immunization tracking, survey
analysis, incident and exposure tracking
 All venue of CHN
 Omaha System

 Research-based, comprehensive taxonomy designed to generate meaningful

data following usual or routine documentation of client care
 Developed in 1970 by Visiting Nurse Association (VNA) of Omaha
 3 components
1. Problem classification scheme
2. Intervention scheme
3. Problem rating scale for outcomes
 Has 44 nsg problems each with signs and symptoms
 These problems are organized into 4 broad domains- environmental,
psychosocial, physiologic and health- related behaviors
 Problem may be— health promotion, potential, or deficit impairment/actual
 Patient-individual or family

Community Health Systems

 Computerized IT systems used by community health agencies, local health dept,

programs, etc.
 Support health promotion and dse-preventive programs, statistical info
 Assist in decision making for mgt of nursing facilities

Address areas of:

1. Healthcare programs
2. Agencies
3. Settings
Community Health Systems in CHS:

 Categorical systems—generally count, track and identity heath status of

registered clients.
 Screening programs—detect people afflicted with specific disease or
predisposing health condition. Results of screening tests are tracked for data
analysis.
 Client registration systems—Identify residents eligible for CHN services in clinics
and homes.
 MIS—mgt of statistical and operational needs of the agency and professionals.
 Statistical reporting systems—epidemiologic and immunization data.
 Special purpose systems—collect data for administering a specific program.

Home Health Information Systems

 Support home, healthcare, hospice and private duty programs

Telemedicine

 Replace face-to-face home visits

 Electronic transfer of medical info and services (voice, data and video) from one
site to another using telecommunication technologies

Includes:

 Telemonitors w/ peripheral biometric attachments

 Videophone w/ 2-way audio video to see client activity
 In-home msg devices w/ diseaes mgt education, advice and VS monitoring
 Video camera to monitor care delivery
 Video conferencing—hospice care
Community Health Telemedicine Systems

 Link patient's homes to healthcare facilities and professionals, homecare workers

to their supervisors.

Computers with Internet applications used by pts to:

 Assist in self-diagnosis and preventive medicine

 Reduce OPD visits
 Self-directed triage
 No "worried-well"

Community Health Network Systems

 Computer terminals placed in homes of "heavy users of healthcare"—families

with young kids, pregnant women, disabled, elderly, etc
 Performs triage

Home High-Tech Monitoring Systems

 Monitoring devices that transmit VS and other critical data (ex. post-surgical)
 Remote defibrillator—diagnose and resuscitate homebound pt
 Alert systems—homebound pt signal for help in an emergency

Educational Technology Systems

 Technological media to interact with and educate pts in the home and community
 Home consultation
Teaching strategies using information technologies include:

 Active learning
 Personalization
 Individualization
 Cooperative learning
 Contextual learning
 Evaluation strategies

Ambulatory Care

 d/t increased cost of healthcare, there is a move away from inpatient to

ambulatory setting.
 Ambulatory clinics and surgery centers, diagnostic lab, HMO, birthing centers,
school health services.
 Prison health centers, office-based surgery center, pain mgt clinic, mobile clinics,
dialysis centers, laser centers, women's health center, sleep centers.

Issues in Ambulatory Care

 Increased accountability
 Need for continuous and documented service improvements
 Pressures to control utilization
 Protection of confidential information

Applications in Ambulatory Environment

 Same as in-patient arena:

-Registration Billing Accounts receivable and payable
-Pt and staf scheduling
-Managed care functionality
Role of Nurse Using Informatics in Ambulatory Setup

 Nurse is a user of data in the system

 Objective—take data and put together in meaningful ways to make information,
then knowledge
 Nurse is involved in selection of automated system based on needs assessment
of the environment
 Nurse implements automated system for administration, financial or clinical use

ADMINISTRATIVE AND CLINICAL HEALTH INFORMATION SYSTEMS

Introduction

 Healthcare organizations integrate a variety of clinical and administrative types of

information systems.
 These systems collect, process and distribute patient- centered data to aid in
managing and providing care.

Communication Systems

 Communication systems promote the interaction between healthcare providers

and patients.
 Communication systems have historically been separate from other types of
health information systems and from one another.
 Departmental Collaboration and Knowledge/Infomation Exchange

 A multidisciplinary approach assures that systems will work in the complex

environment of healthcare organizations with diverse and complex patient
populations.

I. Purposes of Documentation

 Professional responsibility
 Accountability
 Communication
 Education
 Research
 Satisfaction of Legal and Practice standards
 Reimbursement

I.a. Documentation as Legal Responsibility

 Documentation (sometimes reporting, charting or recording) can be described as

any electronic or written information or data about client interactions called or
care events that meet both legal and professional standards (College of
Registered Nurses of British Columbia, 2012)

I.b. Documentation as Accountability

 Care providers are responsible and accountable for their own practice and
documentation is part of that accountability.
 Did you know that your standards of practice and competencies are linked both
indirectly and directly to your documentation?

I.c. Documentation as Communication

  Documentation is a communication method that confirms the care provided to the
client.
 It clearly outlines all important information regarding the client.

L.d. Documentation as Education

 The medical record can be used by health care students as a teaching tool.

I.e. Documentation & Research

 The medical record is a main source of data for clinical research.

L.f. Legal & Practice Standards

 Nurses are responsible for assessing and documenting that the client has an
understanding of treatment prior to intervention.
 Two indicators of the above are Informed Consent and Advance Directives.

T.g. Documentation & Reimbursement

 Accreditation and reimbursement agencies require accurate and thorough

documentation of the nursing care rendered and the client's response to
interventions.

II. Principles of Effective Documentation

 Elements of nursing process needed to be made evident in documentation

include:
o Assessment
o Nursing Diagnosis
 o Planning and Outcome identification.
o Implementation
o Evaluation
o Revisions of planned care.

IV. Methods of Documentation

 Narrative Charting
 Source-oriented charting
 Problem-oriented charting
 PIE charting
 Focus charting
 Charting by exception
 Computerized documentation
 Critical pathways

V.a. Kardex

 A summary worksheet reference of basic information that traditionally is not part

of the record.
Usually contains:
 Client data (name, age, marital status, religious preference, physician, family
contact).
 Medical diagnoses: listed by priority.
 Allergies.
 Medical orders (diet, V therapy, etc.).
 Activities permitted.
V.b. Flow Sheets

 Vertical or horizontal columns for recording dates and times and related
assessment and intervention information.

Also included are notes on:

 Client teaching.
 Use of special equipment.
 IV Therapy.

V.c. Nurse's Progress Notes

 Used to document:
 Client's condition, problems, and complaints.
 Interventions.
 Client's response to interventions.
 Achievement of outcomes.

V.d. Discharge Summary

 Highlights client's illness and course of care.

Includes:

 Client's status at admission and discharge.

 Brief summary of client's care.
 Intervention and education outcomes.
 Resolved problems and continuing care needs.
 Client instructions regarding medications, diet, food-drug interactions, activity,
treatments, follow up and other special needs.
Nursing Minimum Data Set

 The elements that should be contained in clinical records and abstracted for
studies on the effectiveness and costs of nursing care.

Focuses on:

1. Demographics.
2. Service.
3. Nursing care.

Nursing Diagnoses

 A clinical judgment about individual, family, or community responses to actual

potential health problems or life processes.

Nursing Intervention Classification

 A comprehensive standardized language for nursing interventions organized in a

three-level taxonomy.
1. Independent
2. Dependent
3. Collaborative

Nursing Outcomes Classification

 A classification system that comprises 190 outcome labels and corresponding

definitions, measures, indicators, and references.
Telephone Reports and Orders

Telephone communications are another way nurses:

 Report transfers
 Communicate referrals
 Obtain client data.
 Solve problems
 Inform a client's family members regarding a change in client's condition.

Incident Reports

 The documentation of any unusual occurrence or accident in the delivery of client

care, such as falls or medication errors.

Focus Charting

 Describes the patient's perspective and focused on documenting the patient's

Current status, progress towards goals, and response to interventions.
 The focus might be patient strength, problem, or need.
 Topics that may appear in the focus column include:
1. Patient's concerns and behaviors
2. Therapies and responses
3. Changes of condition
4. Significant consultation, monitoring, management of ADLS or assessment
of functional health events such as teaching, patterns.

Focus Charting: Purpose

  Brings the focus of care back to the patients' concerns. Instead of a problem list
or list of nursing and medical diagnosis, a focus column is used that incorporates
many aspects of patient care.

The Principal Advantage of Focus Charting

 The holistic emphasis on the patient and his/her priorities including ease in
charting.

Focus Charting: Objectives

 To easily identify critical patient issues/concerns in the progress notes.

 To facilitate communication among all disciplines.
 To improve time efficiency with documentation.
 To provide concise entries that would not duplicate patient information already
provided on flow sheet/checklist.

Focus Charting: General Guidelines

 Focus charting must be evident at least once every shift.

 Focus charting must be patient-oriented not nursing task-oriented.
 Indicate the date and time of entry on the first column.
 Separate the topic words from the body of notes.
 Signature and Name for every time entry.
 Document only patient's concern and/or plan of care and general notes are not
allowed.
 Document patient's status on admission, for every transfer to/from another unit or
discharge
 Follow the DO's of documentation.
 Use appropriate ink color (per institutional policy).
Focus Charting: Specific Guidelines

 Begin with comprehensive assessment using IPPA.

 Include in the assessment, collection of information from patient, family, existingg
health records.
 Establish a focus of care to be addressed in the progress notes.
 Document the four elements of focus charting:
 Focus—Identifies the content or purpose of the narrative entry and is
separated from the body notes in order to promote easy data retrieval and
communication.
 Action—describes the nursing interventions (independent, basic and
perspective) past, present or future.
 Response—describes the patient outcome/response to interventions or
describes how the care plan goals have been attained.

Documentation DO's and DON'T's DO's:

DO's:

 Do read what other providers have written before providing care and before
charting.
 Do time and date all entries.
 Do use flow sheet/checklist. Keep information on flow sheet/checklist Current.
 Do chart you make as observations.
 Do write your own observations and sign over printed name. Sign and initial
every entry.
 Do describe patients' behavior.
 Do use direct patient quotes when appropriate.
  Do be factual and complete. Record exactly what happens to patient and care
given.
 Do draw a single line thru an error, mark this entry as "Mistaken" and sign your
name.
 Do use next available line to chart.
 Do document patient's current status and response to medical care and
treatments.
 Do write legibly.
 Do use standard chart forms.

DON'T's:

 Don't begin charting until you check the name and identifying number on the
patient's chart on each page.
 Don't begin charting until you check the name and identifying number on the
patient's chart on each page.
 Don't chart procedures or chart in advance.
 Don't begin charting until you check the name and identifying number on the
patient's chart on each page.
 Don't chart procedures or chart in advance.
 Don't clutter notes with repetitive or frequently changing data already charted on
the flow sheet/checklist.
 Don't fake or sign an entry for someone else.
 DONT change an entry because Someone tell you to.
 Don't label a patient or show bias.
 Don't try to cover up a mistake or accident by inaccuracy or omission.
 Don't "white out' or erase an error.
 Don't throw away notes with an error on them.
 Don't squeeze in a missed entry or "leave space" for someone else who forgot to
chart.
 Don't write in the margin.
 Don't use meaningless words and phrases, such as "good day' or "no
complaints"
 Don't use notebook, paper or pencil