Mutlidisciplinary Team Terminology - (SNOMED-CT) Systematized Nomenclature of Human and Veterinary Medicine Clinical Terms- clinical terms covering
... [Show More] nurisng, medicine, & allied health
Standardized Terminology Supports - Data Mining
PHR - Private Health Record - Lifetime health record, supplied by ind., healthcare providers, pharmacies, therapist, lab test, - Controlled by the consumer,
E-Sign - Same legal status as a hand written signature
MIPPA - Medicare Improvement for Patients & Providers Act provides - financial incentive for e-prescribing to providers
HIPPA provides - legal protection for personal health info, set standards for elect. data interchange of claims data, named specific code sets for use in Medicare related transactions, & Privacy
ARRA provides - provide funds for adoption of technology & provides the right for every individual to receive and electronic copy of EHR
HITECH provides - strengthened HIPPA security & privacy protection, & provides financial incentive for the user of EHR
EMR -electronic medical record provides - Legal record often restricted to a Single episode of care , building block of EHR,
EHR- Electronic Health Record is - Longitudinal record that includes client data, demographics, clinician notes, medications, diagnostics.
- Major driver for US Adoption are "Meaningful Use" financial incentives from HITECH part of ARRA
Affordable Care Act provides - guarantee access to healthcare, encourage PCP,
Data is - collection of #, characters, or facts (body weight- 128lb), little meaning alone
Information is - Collection of data examined for patterns or structure that can be interpreted. ex notes prior BP and informs doc
Knowledge is - Synthesis of info from several sources to produce a single concept or idea, ex read a journal about BP
Computer Technology is - collection of data for analysis, which can be used to justify the efficacy of particular interventions & improve quality of care
HIS HEalthcare Information System is - Administrative System + Clinical Information System,
Clinical Systems include: order entry, radiology, pharmacy, physician management system
Adm system : non clinical, demographics, scheduling, risk mgmt, decision support,
Administrative System includes these functions - Managing nonclinical, client-related information (demographics, codes for procedures, & Insurance
Hippa - Compliant Codes inlcude - (ICD) International Classification of Disease, Common Procedural Terms, (ABC) Alternative Billing Codes,
ANA recognizes these terminologies - (CCC) Clinical Care Classification, (ICNP) International Classification of Nursing Practice, NANDA, NIC, NOC, the Omaha System, (PNDS) Perioperative Nursing Data Set
Teleconferencing is - use of computers, audio, & video equip. and high-grade dedicated telephone line, cable/sat connections to provide interactive communication between 2+ ppl at 2+ sites
Elearning provides - electronic media to present instruction, it allows users to skip information they already know
Distance Education is - the use of print, audio, video, computer, or teleconference capability to connect faculty & students; Can take place in real time or on a delayed basis
Web Based Instruction is - the attributes & resources of the internet to deliver & support education
Telehealth is - use of telecommunication technologies & computers to provide healthcare info & services to clients at another location
- consumers are chronically ill, isolated, assisted living families
- decrease er visits, decrease LOS, decrease Admissions, increased productivity for clinical
Telenursing is - telecommunications & computer technology for the delivery of nursing care & services to clients at other sites
Issues with telehealth & telenursing are - lack of reimbursement, infrastructure, plug-play standard, license & liability issues, & concerns r/t to client privacy & confidentiality
EBP- Evidence Based Practice is - the use of research & evidence to inform clinical practice, an approach to provide care that integrates nursing experience & intuition with valid and current clinical research to achieve the best patient outcomes
EBP provides - standardized best practices, reduce time that the nurse spends gathering & assessing data, provide care w/ clinical research
EBP contributes - increased job satisfaction, improved quality of care
how a nurse uses data - 1. accessing information
2. collecting data
3. Inputting Data
4. analyzing data
quantitative research - concerned with objectivity, tight control over situations, define relationships between variables, seek correlation between data, ex. tries to discover how an intervention has impacted subjects IN DEPTH, tangible relations between variables,
qualitative research - concerned w/ finding out more about the human experience, accomplished thru interviews & over a long period of time, ex. how an intervention could impact an entire population, content analysis, computers can code responses to questionnaires which then can be inputted in the informatics sys for analysis,
types of patient information are - 1. standard
2. general
3. targeted
4. personalized
5. tailored
Standard patient information is - describes procedures that all patients will encounter, ex temperature or weight
General patient information is - ask consumers to follow a PREVENTIVE course of treatment that applies to everyone ex yearly physical
Targeted patient information is - geared toward ppl who are a SUBSET of the general population ex men >40 prostate exam
Personalized information is - gives info about a SPECIFIC condition the consumer has been diagnosed with ex. DMII [Show Less]