ANNE.PPT.pptxnursing informatics notes nursing

Obstetrics and gynaecological nursing notes

1. NURSING INFORMATICS

2. Introduction: Nursing informatics is the speciality that integrates nursing science with the multiple information and analytical science to identify, define, manage and communicate data information knowledge and wisdom in nursing practice. Health informatics focus on information technology to positively impact the patient physicians relationship through effective collection and understanding.

3. Terminology : Integrated : To bring together curative and development aspect of patient care into one strategy. Ethical : Medical ethics deal with those ethical principles that govern professional conduct in medicine. Legal : Legal Medicine is the board concept incorporating both legal and forensic training.

4. Aggregation : Massing or clumping of materials together. A clumped mass of occurrence of more cases of a given disorder in close relatives of a person with the disorder than in control families. Synchronous : Synchronous communication live and real time, happening, exiting or arising at precisely the same time.

5. Definition: Informatics: Informatics is the study of structure behaviour, and interaction of natural and engineered computational systems. Health informatics: It is focuses on the information technolcogy to positively impact the patient,physician,relationship effective collection,safeguarding and understanding of the health data.

6. Nursing informatics: Nursing informatics as the use of computers technology to the support nursing including clinical practice, administration,education and research. Nursing informatics as the development and evaluation of application, tools, processes and structure which assist with the management of the data in taking care of patients or supporting the practice of nursing.

7. Meaning : Informatics comes from French word informatique which means computer science. Informatics is defined as computer science and information science.

8. History In 1950 health care began to use computers. In 1970 nursing began to realize the importance of computers to the nursing profession. In 1980 medical and nursing informatics specialities emerged. In 1993 the American nursing informatics association . Nursing informatics has experienced rapid growth in the past 40 years and it does not appear to be slowing.

9. General purpose of nursing informatics: Computer generated client documentation. Integrated systems allow nurses to make notes that everyone can access meaning that each change shift runs smoothly. Nursing informatics can also help with closing instruction, staff assignments, and lab results. Another function of nursing informatics is to help create care plans. Nursing informatics makes use of the information coordinated by technology to help nurses make better decisions.

10. Types of nursing informatics: Human computer interaction Medical informatics Electronic medical record system Electronic health record Medical information system Clinical decision support system

11. Human computer interaction: Human computer interaction concerned with the interaction between people and computers. As the study of how people design, implement, and evaluate computers systems in the context of users tasks and work . Medical informatics: It is the systematic application of information, computer science, and technology to public health practice, research and learning.

12. Electronic medical record system: An electronic collection of the medical information about a person that is stored on a computer. An electronic medical record include information about the patient’s health history, such as diagnose, tests and treatment plans. Electronic health record: An electronic health record is a digital version of a patients paper chart. EHR are real time, patient centered records that make information available instantly and securely to authorized users.

13. Medical information system: An interconnected set of components used to collect, store, process and transmit data and digital information. Clinical decision support system: Clinical decision support provides clinicians, staff, patients or other individuals with knowledge and person specific information, intelligently filtered to enhance health and health care.

14. Trends in nursing informatics: Past nursing informatics: Nursing informatics was the first defined as the use of computer technology yo support nursing. The first generation of nursing information system was designed to speed paper work and communications . Until 1948 nursing primary care remained in the home.

15. Present nursing informatics: Although the history of nursing informatics extends only some twenty years. Today nursing informatics simplifies documentation and automates the transmission of patient via connected devices to provide access by nurses, physicians and patients.

16. Future nursing informatics: Has introduced new challenges and opportunities along with new computer application. Nursing informatics future trends also will support patient data analysis. Increased connectivity will improve knowledge sharing collaboration between hospitals, doctors, and patients on a global scale.

17. Nursing informatics uses in hospital, community, education, and research: Nursing informatics in hospitals : Storage of the patient data: Data has become an important part of many health care. Nursing informatics is part of the development. To improve the quality of care and out comes. Computerized presentation generated nursing care plans and critical pathways. Computerized self-evaluation.

18. Medical data-monitoring devices that record vital signs and other. Create an integrated clinical system.

19. Nursing informatics in community They can record data about their health National rural health mission Primary health center Automated staff scheduling. E-mail for improved communication. Cost analysis and findings trends for budget purposes. Quality assurance and outcome analysis .

20. Nursing information in education Computerized record keeping. Computerized assisted instruction. Distance learning- web based course and degree programs Power point and ms word for preparing slide-presentation software preparing handout . Classroom technologies. Internet resources formal nursing courses and degree programs. Student and course management.

21. Nursing informatics in research Computerized literature searching. Medicine and web sources. Uses of soft-ware(SPSS). The ability to find trends in aggregate data, that is data derive from large population. For research dissemination. Effective data management and trend finding include the ability to provide historical or current data reports

22. Role of the nurse in nursing informatics: Registered nurses go beyond providing clinical care, to take on roles in operations, education, leadership and technology in today’s health care system. Nursing informatics allows nurses to deliver evidence-based and patient centered care, improve human health and advance medical research .

23. Role of administrator nursing informatics: Improve safety by utilizing technology to facilitate the collection, analysis and reporting of higher quality data related to patient safety issues and health. To prevent medical errors and allow for better monitoring and reporting.

24. PATIENT RECORD SYSTEM: Definition: Patient record is a permanent written communication that documents information relevant to the health care management. Purpose: Provide information on disease condition Data for planning and evaluation to document clinical case history

25. To help in future program planning Evaluation of services to assists in continuity of care Research to furnish proof of type and quality of care Types : Dedicated patients health record Paper based record system Health summaries

26. Dedicated patients health record: A term used to describe the collection information generated to record the clinical care and health status of an individual or health. Paper based record system: Medical records are combination of self-reported patient information and clinical diagnostic notes traditionally stored on paper based mediums. Health summaries: Health system summaries are standalone, concise documents summarizing the main elements of a country’s health system in an engaging policy relevant way.

27. Principles: Minimum records serve to document the history of the patient. All entries to records should be signed put the data and time on all records. Record should be accurable and recorded in such a way that the meaning is clear Record should be readable.

28. Importance : For individual and family: Records serve to document the history of the client Records assist in the continuity of care Records serve as evidence to support or to manage or face the legal questions that arise. Records serve to recognize the health needs and can be used as a research and teaching tool. :

29. For the doctor: Serve as guide for diagnosis, treatment, follow up and evaluation of services. Indicate progress and continuity of care Help self-evaluation of medical practice Protect the doctor in case of legal issues. Records may be used for teaching and research.

30. For the nurses: Provide with documentation of services rendered Provide data essential for planning and evaluation of services for further improvement Serves as a guide for professional growth. Enables to judge the quality and quantity of work done. Indicate plans for the future .

31. For the authorizes: Provide the management with statistical information necessary for decision in regard to utilization of resources, planning for administrative control and future references. Help the supervisor evaluate the services rendered, teaching done and a person’s action and reactions.

32. Value of nurse’s clinical record: Provide baseline data for further plan of action For diagnostic and treatment ( eg ) Evidence for patient care management To evaluate the workload, past and present medical conditions and evaluate the nursing care. Scientific and research purpose. For legal purpose: Legal protection to hospital doctor’s and nurses

33. Issues in patient record systems: Integrated systems require consistent use of standards in eg.Medical terminologies. Ethical, legal and technical issues linked to accuracy security confidentiality. Common records structures Clinical information standards and communication protocols. Security and confidentiality of information Patient data quality: data sets, data dictionaries Staffs efficiency

34. Role of nurse in patient record systems The patient has a right to inspect and copy the record after being discharged. Failure to record significant patient information on the medical records make a nurse guilty of negligence. Medical record must be accurate to provide a sound basis for care planning. Errors in nursing charting must be corrected promptly in a manner that leaves no doubts about the facts. In reporting information about criminals acts obtained during patient care. :

35. Role of administration in patient record systems: It helps doctors and care givers to minutely assess and give the best of medical facilities to the patient. In addition a patient’s medical history allows him/her to take steps to reduce his or her risk. A patient medical records helps healthcare providers arrange for regular checkup and tests for the people with medical condition.

36. A patient medical history can identify the changes of their probability of having lifestyle diseases like diabetes and heart attacks. The patient’s health records and history also can provide information about the risk of more condition.

37. ELECTRONIC MEDICAL RECORD: Definition: A electronic medical record system is a type of clinical information system which dedicated to collecting, storing, manipulating and making available of clinical information. The central focus of such systems is clinical data and not financial or billing information.

38. Components Result reporting in treatment, medication and lab tests Data repository of allergies and complains Decision support in physician, nurse and other clinician’s note. Clinical messaging and e-mail Documentation of flow sheets( vital signs, input and output problem lists) Order entry of Discharge summaries

39. Benefits : General: Improved data integrity: readable, better organized, accurate, complete Improved productivity: access the data Increased quality care Increased satisfaction for care giver, easy access to client data.

40. Nursing Decreased redundant data collection Allowed data comparison form prior visits Improved documentation and quality care Supported timely decision

41. Health provider: Improved documentation, reporting Prompted to ensure administration of treatment and medication Improved efficiency: eligibility, early warning of status changes

42. Patient : Decreased wait time for treatment Increased access/control over the health information Increased use of best decision support Greater clarity to discharge instruction Alert and reminders for appointments and scheduled tests

43. Technical features for EMR: Electronic health record are a vital part of health contain a patient’s medical history, diagnoses, medication, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results.

44. Issues of EHR: The technical problem: Connecting to the system and internet can be more difficult for a system is located in as rural setting over an urban region. The cost of use: Advances in health information technology, such as EHR, can be expensive in both implementation and usage.

45. The work flow break up: Unfortunately getting paid said sometimes EHR implementation can mess up the workflow in a practice entirely if it is not customized to fits its purpose properly. The concerns with privacy: Some health care providers and patients may be concerned bout medical privacies when using EHR.

46. Legal issues of electronic health record: Failure to maintain patient privacy and compliance. Have error free maintenance lack of clarity related to informed consent Need to have a backup plan related medical malpractice risk Health records can be hacked failure to retain healthcare data for the legally stipulated periods.

47. Role of administration in electronic medical records: Medical record contains the patient’s identification information the patient’s health history and medical examination findings. Helps care provides give quality care by allowing quick access to patient records resulting in more efficient care. Hospitals administrators ensure that operate efficiently and that medical staffs members are adequately trained and supported.

48. Role of nurse in electronic medical records: Nurses uses modern technology to manage and organize patient health information. Categorizing patient medical record Making them accessible and accurate for insurance purposes and various database.

49. E- NURSING: Definition: The use of computer or electronic device in some way to provide training, education and learning. E- nursing comprises of all forms of electronically supported learning and teaching.

50. Goals: To enhance nurses to benefit from the developments in information, communication and technology. To improve nursing and patient information. To encounter challenge owing to emergence of new technology.

51. Modalities of E- nursing: Individualized self-paced E –learning online: When an nurse accesses learning resources such nursing database online through an internet. Individualized self-based E – learning online : When an individual nurse learner is using nursing database or a computer assisted learning packages offline.

52. Group based E – learing synchronously: When a group of nurses are working together in same time through internet. Group based E – learing asynchronously: When a group of nurses are working over internet and they exchange themselves with a time delay.

53. Style of E – nursing: Offline and online activities: Learning teaching activities takes place while offline example not connected to an internet learning activities takes place while online example connected to internet.

54. Synchronous and asynchronous: Activities within synchronous learning, Learning and teaching takes place in same time(real time) . Within asynchronous learning the teaching learning activities takes plalce with time delay(time-shift). Different multimedia assets: The activities are carries out through more than one media.

55. Different didactical interactions : Approaches can be used such as assignment, assessment, pre-tests, discussion, reading, workshop, demonstration, participating in a simulation ect . Different way of delivering content: Various way to deliver the content are computer, TV, mobile phone, ipodect . Every device has its own characteristics, advantages and disadvantages

56. Self – study : Learning can be both ways: individualizes as well collaborative in e learning. Formal and informal learning: Informal learning is unstructured, unplanned formal is a learning that is planned with specified learning objectives.

57. Importance: To organization improve training costs. Decrease material costs, increased productivity, and standardization. To learners real time access cost effective interactivity good learning environment improve retention individualized learning. To organization/ community ongoing access to resources. Knowledge management. Encourage sharing of resources.

58. E – Health term: Doctors Nurses Pharmacists Technicians Administrator

59. Issue e – nursing: Caring(essence of nursing is contact and engagement with people, which involves physical closeness, intimacy) Empowerment Self – reflection and expression Confidentiality Networking problem Patient education community development

60. Advantages: It enhances innovative teaching It promotes self-direct learning Convenient for the learner It promotes internet use E- learning saves time and place for learning

61. Disadvantages: Some forms of e – learning perceived as isolating from the personal touch. Nurses may not have the IT skills needed to take advantages of learning.

62. Role of nurse in e – learning: Health advisors Internet guides to help clients select reliable information resources Support group liaisons Web information providers Nurses need to be involved in the design and implementation of e health portals and programs that provide the best possible experience for health care clients.

63. Role of administration in e – learning: Increase retention and application information Improve information and knowledge of nursing practice. New models of nursing practice and health services delivery will be supported.

64. TELEMEDICINE Definition: The delivery of health care services of health care professionals using information and communication technologies to people living distant areas to exchange information.

65. Objectives: To provide specialized medical advice To monitor patient condition To guide other medical staff about treatment procedure Share patient data among institution for research purpose

66. Types: Store and forward telemedicine Remote monitoring Real time interactive services .

67. Store and forward telemedicine Store and forward telemedicine surpasses the need for the medical practitioner to meet in person with a patient. Instead patient information such as medical images or biosignals can be sent to the specialist as needed when it has been acquired from the patient.

68. Remote monitoring Also known as self – monitoring or self - testing, remote monitoring uses a range of technological, devices to monitor the health and clinical signs of a patient remotely. Real time interactive services Interactive services can provide immediate advice to patient who require medical attention. There are several different mediums utilized for this purpose, including phone, online, and homevisit .

69. Benefits: Window to expertise care Economic for hospital and patient Reduce the stress in patient and relatives Save travel time of specialist and patient. Good for education and research purpose.

70. Staffing Head of the department Consultant Network manager Program manager Web developer Telemedicine technician Telephone attendant

71. Location: Location can be located at any non prime location way form the patient traffic near to communication system satellite. Layout: Reception Telemedicine conference hall Telemedicine library Cafeteria Restrooms

72. Role of nurse in telemedicine: Accessing, observing, and speaking to patients. Recording details and symptoms of patient medical history and current health. Preparing patients for exams and treatment.

73. Administering medication and treatment, then monitoring patients for side effects and reaction. Performing wound care, such as cleaning and bandaging them. Operating and monitoring medical equipment. Educating patients and family members on treatment and care plans, as well as answering their questions.

74. Role of administrator in telemedicine: Technology can play a facilitating role particularly in reaching out too remote location In this method of treating and diagnosing patients remotely through communication

75. TELENURSING Definition : Tele nursing refers to the use of telecommunication devices and information technology to provide nursing care from a distance to isolated group of people. Objectives: To deliver care and expertise For curative, preventive and rehabilitative For training and information.

76. Qualification: Associate degree in nursing Bachelor’s degree in nursing Pass the NCLE receive RN licensure Certificate Telehealth nurse

77. Scope in telenursing Assistance to physicians in the implementation of medical treatment protocols Nurses Actually view healing wounds Provide routine assessment and follow up care. New technologies have added a visual component to the interactions that augments the historic audio exchange

78. Home care In normal home health care one nurse is able to visit up to 5 – 7 patients per day. Using tele nursing one nurse can visit 12-16 patients in same amount of time. Principles: Improve and enhance the quality of care Existing health care services Reduce the delivery of unnecessary services.

79. Guidelines for tele nursing practice: Tele nursing consulation need to be structured to provide optimal care to the patients. The following elements to be considered before beginning any tele nursing consultation. Context Identification RN and patients Mode of communication

80. Consent Assessment and communication to the patient related information with RMP Patient management Professional accountablitiy and responsibilities of the registeres nurse.

81. Legal and ethical issues in Tele nursing: Legal issues: Licensing Scope and practice Safety Security Accountability Legal competence

82. Ethical issues: Central and concept in nursing Communication skills competing interests Competing interests

83. Advantages To increases the access to health care services To reduce cost To reduce the visiting / waiting / unnecessary visit to hos [ital. To provide immediate health care information to solve the problem Medicare reimbursement Improvement resource and time allocation Help solve increasing shortages of nurses Minimise the length of hospital stay.

84. Disadvantages: In a medication administration example, patient made medication administration error Stress and potential error False diagnosis Networking connection error

85. Role of nurse in tele nursing: Recording vital signs including oxygen level. Monitoring patient progress and updating patient medical records as needed. Responds to patient experiencing cardiac pain. Technical skill is needed by nurses.

86. Role of administrator in tele nursing: Clinical services can be realistically delivers via health. Billing codes should also be used using tele health services. Parallel method: The selected new system is installed and operated with current system. This method is expensive because of duplicating facilities and personal to maintain both system.

87. 3.Modular method: This is generally recognized as pilot approach means the implementation of a system in the organization on a piece meal basis. Advantages: The risk of system failure is localised. The major problem can be easily identified. It supports and enhances the overall decision making process.

88. Disadvantages: Highly sensitive, require constant monitoring. Budgeting Lack of flexibility to update. Effectiveness decrease due to frequent changes in top management.

89. Role of administrator management and evaluation system: Management information system are used to process information both at strategic and operational level to monitor activities. Access and plan new services. Monitor trends which enables senior managers. To effectively manage the strategic direction of an organization.  

90. THANK YOU