TERMINOLOGIES

• terminologies 1. ABC codes 2. Perioperative Nursing Data Set (PNDS) 3. SNOMED CT 4. International Classification for Nursing Process (ICNP) 5. Patient Care Data Set (PCDS) 6. NANDA - North American Nursing Diagnosis 7. LOINC - Logical Observation Identifiers Names and Codes
• ABC CODES - mechanisms for coding integrative health interview by clinician for administrative billing and insurance claims. - Includes complementary and alternative medicine interventions and codes that map all NIC, CCC, and Columbia system interventions.
• PERIOPERATIVE NURSING DATA SET (PNDS) - Universal language for perioperative nursing practice and education; standardize documentation of perioperative data in all perioperative settings
• SNOMED CT - Core clinical terminalogy containing over 357,000 healthcare concepts with unique meanings and formal logic-based definitions organized into multiple hierarchies
• Advanced Termnilogy System The primary motivation for standardized terms in nursing is the need for valid, comparable data that can be used across information system applications to support clinical decision-making and the evaluation of processes and outcomes of care
• Information Technology System Applicable in Nursing Practice 1. Hospital/ Critical Care Applications 2. Community Health Applications 3. Ambulatory Care System 4. Emergency Preparedness and Response 5. Administrative Assistive Devices and Workplace Technologies 6. Telehealth
• CRITICAL CARE - area of expertise within the health professionals that focus specifically with human responses to life-threatening problems.
• Special Area ○ Intensive Care Unit ○ Pediatric Intensive Care Unit ○ Emergency Care Unit ○ Neonatal Intensive Care Unit ○ Recovery Room
• Critical Care Applications - Areas where patients require complex assessment, high intensity medication, continuous therapy and interventions, unrelenting nursing attention and continuous watchfulness
• CRITICAL CARE INFORMATION SYSTEM - Provide real-time resource utilization data and management of information and access critical care areas through the integration of the medical facilities in the ICU to an inteligent computer system which is capable of processing all of these data.
• CRITICAL CARE INFORMATION SYSTEM Patient profile generates real time and historical reports on indicators - Bed оссupancy - Delayed discharges - Readmission rates outcomes
• The Medical Information Bus (MIB) provides a generalized method of attaching patient monitoring devices to a common interface.
• Goal of MIB 1. To communicate accurate, useful information to clinician that will be used in decision-making. 2. To provide care to critically-ill patients that requires processing information collected from multiple sources. 3. To provide enough time to collect information and to communicate it to many health care providers. 4. To accurately monitor rapid changes in patient condition and the therapy provided in response to these changes 5. To evaluate outcome of intervention in order to measure cost effectiveness and describe quality of patient care
• Information from Different Areas ➢ Clinical Laboratory ➢ Pharmacy ➢ Radiology ➢ Pulmonary ➢ Cardiology ➢ Bedside nurse charting
• AMBULATORY CARE - Covers a wide range of HCS that are provided for patients who are not admitted overnight to a hospital. ● Outpatients clinics ● Emergency room ● Diagnostics and Imaging centers ● Primary care centers ● Community health centers ● Mental health care
• COMMUNITY HEALTH INFORMATICS - Creating information system at the population level is somewhat difficult due to a very large number of resources, data elements, diverse parameters, components, and information content
• COMMUNITY HEALTH APPLICATIONS ● Collective term for the methodical application of information science and technology to community and public health process ● Focuses on the health information system of the community, it is centered on the majority part of the public. ● Emphasizes the prevention of the disease, medical intervention and public awareness. ● Fulfills a unique role in the community, promoting and protecting the health of the community at the same time
• Hospital information systems, clinical information system, patient monitoring electronic health record focused more on individual and single resource
• Community health information system focused more about the majority of the population.
• COMPUTER BASED SURVEY SYSTEM ★ An experiment involves the collection of measurements or observations about populations that are controlled by the experimenter ★ A survey is an examination of a system in operation in which the investigator does not have an opportunity to assign conditions to the objects of the study
• Health Information System - Captures the scenario or condition where emergency preparedness and immediate response Is prioritized
• Emergency and Response process - Goal is to halt the spread of disease, infection, widespread sickness, epidemics.
• EMERGENCY PREPAREDNESS AND RESPONSE Early informatics contributions to the emergency planning and response agenda have focused largely on surveillance of threat detection and a broader assessment of possible informatics contributions unveils that informatics can also contribute to increasing the efficiency in disaster response as well as providing a telepresence for remote medical caregivers (Weiner, E. E., & Trangenstein, P.A., 2007).
• Administrative Assistive Devices and Workplace Technologies Assistive technology is an umbrella term covering the systems and services related to the delivery of assistive products and services. Assistive products maintain or improve an individual's functioning and independence, thereby promoting their well-being
• TELEHEALTH - Use of telecommunication technologies to provide health care services to clients and provide access to health-related information for both the clients and healthcare worker
• Telehealth Applications 1. Telephone - 911 for emergency and health assistance; Teleconferencing to healthcare community, Call centers dealing with healthcare communication services 2. Computer systems - monitoring and diagnostic equipment ● Advanced wireless applications ● Computerized home health care system (CHHCS)
• COMPUTERIZED HOME HEALTH CARE SYSTEM (CHHCS) Non-invasive sensors are applied directly to patient: ● Monitor vital signs ● Oxygen Saturation ● Breath/ heart sounds ● Body postures & movements ● ECG leads and scanners Interactive communication accessories: ● Microphone, speaker, monitor display, camera
• COMPUTERIZED HOME HEALTH CARE SYSTEM (CHHCS) ISSUES ➢ Legal Issues Regulation and authority on healthcare practice regarding telehealth. ➢ Safety Standards - there is a need to certify care providers who engaged in telehealth as a new medium of delivery. ➢ Security - question of privacy, confidentiality and data security, Data should be in secure lines ➢ Budget Constraints - cost of infrastructure, installation, connection, training and maintenance is high
• EVIDENCE-BASED PRACTICE - provides the most effective and efficient patient care. Implementation of EBP by healthcare professionals results in higher quality healthcare, improved patient outcomes, care standardization, improved workflow, and reduced costs compared to care steeped in tradition or based on outdated policies and practices (McGinty & Anderson, 2008; Melnyk & FineoutOverholt, 2019).
• BEDSIDE DATA ENTRY These allow recording of client assessments, medication: administration, progress note, care plan updating, client acuity, and accrued charges.
• COMPUTER GENERATED NURSING These NCPs are products of nursing system versus a preset database/programs that has built in care plans.
• Electronic Health Records (EHRs) with computerized Nursing Care Plans (NCPs) ➢ Cerner - hospital management system ➢ Pointclickcare - specializes in elderly care facilities ➢ AllScripts - hospital management system ➢ eClinicalWorks - hospital management system ➢ MediTech - hospital management system ➢ ? *Indra - available in PH
• CRITICAL PATHWAYS - A set of structured, multidisciplinary plans of care devised to augment or support the implementation of a clinical guideline or protocol. Range of scope can be as focused utilization of medication to something more complex like a comprehensive patient management plan. It was first introduced in 1990 in the US and the UK. It is evidence based.
• Critical/Clinical Pathway


  A pathway that clearly defines the coverage as well as other time elements to be considered in any of the steps or procedures it has
• Categories of care

  • Assessment
  • Diagnosis
  • Diet Therapy
  • Nursing Care
  • Medical Regimen
• Pathways provide clear expected health outcomes through a list to aid the healthcare provider in evaluating care and patient response
• Outcome criteria also serve as signposts for HCPs in determining what to do next for a particular patient
• Pathways require documentation of Variance
• Variance


  A quality that is divergent or inconsistent with the expected outcome
• Decision support software, computer software programs that organize information to aid in decision making for client care or administrative issues