Module 2

What structured terminology do you use in your clinical practice?
In the emergency department all nurses work under the standards and scope of care in their related to their licensure within the state they work. All patients are triaged and assess by a registered nurse before having a medical screening by the Emergency room physician. Nurses use the NANDA for evaluating needs of of the patient and interventions to include a positive outcome and evaluate the effectiveness of the plan.
The nurse collects the data and information which includes pertinent information about medications, orders and decision making of the MD and it is placed in a structured charting system, and "free texting" if needed. The information is all placed in a electronic medical record. The procedure and diagnostic coding is coded after the physician is completed with the chart by medical records.


How are structured/coded clinical data useful in promoting quality patient care?
The structured/coded clinical data that is collected in the Emergency Room can be electronically sent to the PCP and evaluated to determine continued care for the patient. Hopefully the information flow from the clinical care area has good clarity so that the follow up physician understands what has been done for the patient and the follow-up care that is needed.
This information can increase health information and support evidence-based practice (PP. Fund. 2).

Lauri Morgan

horses

These horses are next to our house. Their were about 10 mares with babies it was great.

Question 3.

How/when might you want to partner with NI colleagues?

When making a program of study on-line or education tool to educate other nurses or primary care physicians about a new standard of care that is to be in your office or department. The informatic practioner could assist with the application process for the curriculum process and participates in the selection process, design, implementation, and evaluation of the systems (Curran, C. 2003).
Lauri Morgan

Question 2

Why will you, as an advanced practice clinical nurse (DNP graduate), need to know about information management and IT?

Information and technology are essential in our nursing field today, it's important that we incorporate these two to keep up with all the new information and technology that continues to grow (Curran, C. 2003). Our field is ever expanding and we want to continue to grow with technology we have to keep up on our IT skills and be knowledgeble about both.
Curran also states that as advanced practice nurses that we need to be competent in our clinical judgements, critical thinking, analysis, judgement, mangement, education, research, problem solving with collaboration, and our communication skills. We need to be open to new technologies and the up and coming information to be able to treat our patients with the best quality care that we can give.
Lauri Morgan

Question 1

1. IT has changed quite a bit, the emergency room has gone to a computer charting called Promed. I have a lot of anxiety about the program, because I feel that the program doesn't have any prompts, so I feel that I'm missing important information that I should chart on my patients. I do like the challenge of computer charting, but I feel the program that we have isn't the best. I seem to be getting better at it though, practice, practice.
We also have a plasma screen on the wall which identifies the different rooms and complaints of the patients. Its seems so high tech and looks good.

Hello, my name is Cooper, my dog is so spoiled, but he had a hard time at first he had puppie strangles. Has anyone heard of it?
Lauri.