Module 1, Question 2 Response

In the hospital where I work, there are clinical educators/IT specialists that are in charge of reviewing and improving our documentation system. Input from the nursing and other healthcare providers that use the system on a daily basis is also encouraged to continually better the system. In my hospital, we have structured charting and unstructured charting, as explained in the power point presentation of module one: Coding and Classification of Clinical Data. There are templates set up to aid in the documentation of the patient physical assessment performed at least once a shift and there are separate templates created for the use of other data entry, such as vital signs and specific nursing interventions. The nurse that admits the patient is initially in charge of creating a care plan for the patient, then each additional nurse that cares for the patient has the responsibility to alter the care plan according to the progress of the patient. For transfers or discharges of patients, there is a process set up as well including certain templates that need to be filled out. Aside from the pre-set templates, we are also encouraged to write free text nurses notes often. This option is helpful in offering plenty of space to describe events or document information without being limited by pre-set templates. In my undergrad nursing program, we were taught and encouraged to use NANDA approved nursing diagnoses, but where I work, the use of these diagnoses isn't explicitly stressed. As for coded data, I personally haven't had too much experience in that up to this point, but I know it exists as well in my hospital. I believe it is used more between the physicians and out-patient services to handle billing arrangements.  

The use of this type of standardized documentation system is beneficial for the patient in many ways. This helps to offer the patient quality care by assuring a continuity of care. The patient information is documented so that all healthcare providers can have access to it in case of questions about whether a certain intervention did or did not happen. It also allows healthcare providers to see trends in patient status, such as vital signs, wt, or urine output, to help track the patient progress or recognize need for intervention. If the documentation is standardized and computerized, the time spent by the healthcare provider documenting is often decreased, allowing more time for patient care. The documentation, if done properly, is a detailed history of everything that has happened to the patient and can act like a safety net for the patient.

Module 1, Question 1 Response

Hello! My name is Brittany Bushman and I am in my second semester of the Acute Care DNP program. Information management as a graduate level nurse and also as a undergraduate level nurse is absolutely essential to provide appropriate patient care. Nursing and patient care isn't possible without information management, and whether we realize it or not while we are working, we are constantly managing data, even if it is simply in our minds. From my understanding from module one, information management includes observing and describing, collecting, recording and reporting, planning, and synthesizing data to create optimal outcomes for the patient and for all involved. I need to know how to manage information in order to, perhaps, look up lab values of my patient, give a shift report to the oncoming nurse, provide effective nursing and medical care to my patients in way of medication administration and symptom management, and document patient care, findings and changes in patient status for appropriate continuity of care and planning, etc. I have been guilty of complaining about the amount of charting that is required by certain hospitals or institutions, but at the end of the day, the documentation is necessary because if it isn't charted, it wasn't done! Effective information management can aid in quickening the process of documentation or information retrieval and allow the nurse more time for quality patient care. Information management also aids in the research end of nursing by documenting trends in medication administration or certain events within a specific research project. There is no end to the important role that information management plays in advanced practice nursing.