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
Tailored Information is
information that focuses Specifically on Ind Based on Specific Conditions , it is typically gleaned from EHR or EMR [Show Less]