Module 1

1. Introduce yourself to the group and include your graduate area.

Hello - my name is Ryan and I'm currently in the DNP program, specializing in Acute Care.

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

Information management is a rapidly expanding component within the healthcare field, which will require an ongoing comprehensive understanding of its function along with all of the components that are involved throughout the entire process. Components that involve: planning, collecting, aggregating, analyzing and disseminating/reporting of related patient data. In my current job as Director of Risk Management I am extensively involved with each of these processes already. I collect specific information related to Patient Incident and categorize them accordingly. Depending on the level and basing the event on a severity index, I am able to determine whether an investigation is required which may include conducting a Root Cause Analysis. This position that I was hired for requires extensive knowledge involving information management, which I hope to be able to supplement as I learn more about this through my graduate education.

3. Describe what is happening related to IT in your clinical area.

Currently our organization is reviewing different forms of computerized charting and is currently considering one system that will allow the Doctors, Nurses and Therapists the ability to input charting entries as well as input and retrieve medication related information from designated terminals located throughout the facility. The Doctors would also have the ability to remotely access certain information through a secured application. Again, the organization is considering several options and prices and may consider a "trial run" of this program in the near future.

4. What structured documentation, standards, and/or coded terminologies do you see within our practice setting (if none, where might they be applicable)?

Structured documentation that is retrievable hospital-wide includes data such as Physician Orders, Scheduled Medications, PRN medications, laboratory tests results, vital signs and assessments.
Additional Standards include the JCAHO standards that are maintained by the facility.
Terminologies include a standardized list of JCAHO / hospital approved list of abbreviations, as well as a comprehensive list of policies and procedures specific to each unit.

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

Structured / coded clinical data is very useful in promoting quality patient care in several ways. The most important advantage that I have recognized involves the reduction in various errors. Medication errors involving transcription are avoided, especially when the MD's input the data directly themselves. Additionally, automatic computerized prompts assist in ensuring that medications are administered as scheduled. When patients are transferred, immediate accurate information specific to their entire record is available. Technology is allowing for cost-effective data backup and secured access which provides for adherence to requirements of accrediting bodies such as JCAHO which are tools for quality care assurance.