Module 1- Introduction

Introduce yourself to the group:

I'm a RN at Primary Children's Medical Center on the Medical Unit and I've been there for about 3 years. I'm a charge nurse and have a speciality role on my unit as the Cystic Fibrosis Expanded Role. I love my job, but working with children means that I'm exposed to a lot. I'm currently stuck at home awaiting the results of a VRP to see if I caught H1N1 from a patient last week. 

I'm almost done with my first year of the Pediatric DNP program. My husband is also in grad school, so right now I live my life in semesters. When I'm not studying I enjoy reading, photography, camping, and hiking.  

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

As an advance practice nurse you are surround by vast amounts of information and it is part of your role to be able to manage this information in an effective manner in order to provide excellent care to patients. Nursing informatics provides the tools necessary to manage this information. From a public policy perspective healthcare informatics has come to the forefront and as graduate prepared nurses we need to be able to understand and utilize new technologies related to healthcare information.

Describe what is happening related to IT in your clinical or practice setting:

• Switch from paper MARs to EMARs and bar code scanning of medications
• Vocera devices for communication
• Changed from paper discharge paperwork to electronic discharge summaries 
• Joined a email list-serve for nursing in the U.S. caring for patients with Cystic Fibrosis
• Use of a hospital wide computer program called "Patient Tracker" to communicate with other disciplines

What structured documentation, standards, and/or coded terminologies do you see within your practice setting? 

We use structured documentation with coded terminologies for the majority of our charting. Currently we use paper charting that also includes an unstructured narrative in which there is great variation between nurses on what is documented and how it is documented. There is a plan to move us to an electronic charting system that structured. We use coded terminologies to document the teaching we done on structured documentation teaching checklists.

How are structure/coded clinical data useful in promoting quality patient care? 

Structure/coded clinical data reduces variability which would make it easier to process data, compile information, and make clinical decisions. The reduction in variability would also make the QI process easier, in that patterns could be assessed more readily, interventions implemented and progress tracked more easily. Less variability also improves communication between care providers and hopefully reduces errors caused by miscommunication.