Nursing Informatics
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Nursing informatics is a field of nursing that incorporates nursing, computer, and information sciences to maintain and develop medical data and systems to support nursing practice and improve patient care outcomes. Technologies that have evolved due to health care/nursing informatics include: Computerized provider order entry (CPOE) Electronic medical records (EMRs) Test results Progress notes Nursing notes Medication records There are three “building blocks” of nursing communications — data, information, and knowledge. Data includes direct observations that do not need interpretation, such as: Patient’s name Age Vital signs Disease history Information is data that has been interpreted. Examples include: Prevalence of hospital-acquired infections by care unit. Percentage of patient care delays in outpatient clinics by specialty Knowledge is the amalgamation of information to identify relationships that provide further observation of an issue. For example: The effect of nurse-patient ratios and patient outcomes Developing care protocols (i.e. anaphylactic reaction protocols, pressure ulcer protocols, etc.) (i.e. anaphylactic reaction protocols, pressure ulcer protocols, etc.) While nurses incorporate all three communication “building blocks” in their daily routines, the three concepts are stored in computer programs and software to assist healthcare providers in providing high-quality, safe patient care across the continuum. Nurse informaticists work to develop communication and information technologies in health care. They also serve as educators, researchers, software engineers, and chief nursing officers. The “building blocks” listed above help develop evidence-based policies and procedures for organizations. Nurses need the information to care for patients safely. They need to access medical histories, medication lists, lab and imaging results, and physician/interdisciplinary team notes to get a complete picture of a patient’s clinical status. They use this information to make decisions efficiently to improve patient care outcomes. Nurse informaticists and other healthcare informaticists (pharmacists, physicians, etc.) play a critical role in the continuous development and improvement of healthcare technology. Communication is inarguably one of the most important aspects of patient safety. The contribution of nurse informaticists in developing and improving technology such as electronic medical records and computerized provider ordering has been crucial in reducing medical errors, patient care delays, and health care costs. For example, before CPOE, nurses must transcribe provider orders by hand. Hard-to-read handwriting and human error caused transcription inaccuracies, leading to medication errors, delays, and omissions. Today, software exists where providers click a button, selecting the right medication, dose, and frequency. Additionally, some programs cross-check orders against the patient’s allergies and duplicate orders to further protect patient safety.
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