6004 Module 1

Introduction: My name is Jeremiah Stevens. I’m in the FNP program. I work in the ICU at Dixie Regional Medical Center and I really enjoy being a nurse there. I live in Sunny St. George Utah. I am twenty nine years old and am single (no kids never been married). I am excited to be in a NP program, though I feel like two and a half years is forever.

1. Why do you as a graduate level nurse need to know about information management?

Information management is an ever developing field. Information management is continually shaping the structure of our current profession. The development of computerized medical records has been improving the health care delivery system for a while now and the knowledge it takes to utilize these programs is priceless. For a top level health care professional to be able to provide the best continuum of care they will have to be efficient in utilizing the latest accepted technologies. A key step in obtaining this knowledge and skills is for a practitioner to know how to find and implement the best evidence practice as it relates to our practice. Information management will better enable prctitioners to get a complete understanding of conditions and treatment because of the availability of many different sources of information. Collaborate care will also help health care professional to be able to work together in treating a patients multiple conditions.

2. Describe what is happeing related to IT in your clinical or practice setting. What structured documentation, standards, and/or coded terminologies do you see within your practice setting?

Information Technology is not only the computer systems we use but also the way we utilize and mange information. IT in the clinical setting of the ICU varies from time to time and situation. Sometimes the incorporation of IT into the clinical setting comes slowly and other times it is thrown at us and we have to be able to quickly assimilate the information to be able to proficiently use the equipment (i.e. A new Ultra sound machine that was purchased to help physicians place central lines. ). Dixie Regional Medical Center (DRMC) started using computerized charting about two years ago. From this change we are able to quickly look at specific findings and track them over a patients stay at the hospital. Shortly after computerized charting was initiated DRMC began to use medication scanners to setup another safety for medication administration. Still there are some departments like the ER and the OR that do not utilize computer charting and this situation forms gaps in accessing information. After working in the ER I have realized that computer charting would be cumbersome but when patients are admitted to the floor this difference in charting can lead to mistakes. Some of our equipment can be hooked up to a data connection and we can get help and guidance from the manufacture of the machine as they link into the machine and diagnose what is going on from a distant location.

3. How are structured/coded clinical data useful in promoting quality patient care?

Structured/coded clinical data is useful in promoting quality patient care for many reasons. One of the primary reasons is communication which can influence many other mediums of care including shift change reports, clinical decision making, anticipating upcoming events, appraising the processes and outcomes of care, recognizing normal variations from trends, and legal purposes. Structured/coding clinical data can also influence clinical pathways and how they are created for given diagnoses. It will be important to know about them and where to find them, so a practice can stay current because practitioner’s offices are not always notified of the changes in coding. It is also important to stay up to date on clinical data coding, since this would influence billing and ultimately how a business is financed.