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1. Chapter 11
NURSING
INFORMATICS/
INFORMATICS
MANAGEMENT
Author
Prof. Dr. Rohini T

2. Learning Objectives
After studying this chapter students will be able to
• Describe the concept of nursing informatics
• Discuss the importance of patient records
• Explain the various types of nursing records
• Describe the use of computers in hospital, college and community
• Explain telemedicine
• Discuss telenursing
• Explain electronic medical records
• Describe electronic health record

3. Chapter Outline
• Nursing informatics
• Patient records
• Nursing records
• Use of computers in hospital, college and community
• Telemedicine
• Telenursing
• Electronic medical record
• Electronic health record

4. NURSING INFORMATICS
The application of computer technology to all field of nursing - nursing
services, nursing education and nursing research. It is a combination of
nursing science, computer science and information science to manage, process,
and communicate nursing data to deliver nursing care and enhance the quality
of nursing care.
- Scholes and Barber
Nursing Informatics system integration of information systems in nursing to
support health efforts. It is a subspecialty of health informatics.
International Council of nurses

5. NURSING INFORMATICS - PURPOSES
• to improve patient care and health management in every aspect
• to obtain evidence-based standards of practice, legislation acts, statistical analysis of the
nursing profession and practitioners at any given time or interval at the macro level
• to study the process and structure of nursing information to support clinical
decision making and the delivery of nursing care at the micro level.
• to streamline data handling. computerization can make it possible to store information
electronically
• to have easy access to sharing vital data within co-workers
• to safeguard personal records of patients while at the same time allowing the
most
comfortable possible access to information for those who need it
• to develop an information sharing network and data handling standards to

6. NURSING INFORMATICS – BASIC CONCEPTS
Data
Information
Knowledge

7. NURSING INFORMATICS - SIGNIFICANCE
• It guarantees the appropriate maintenance and effectiveness of
electronic health care systems.
• It enables experts to gather and examine important patient
data.
• In order to enhance patient care, specialists can use such data to create
significant reports that they provide to other clinicians.

8. Areas of nursing practice Examples of applications
Nursing Clinical Practice (Point-of-
Care Systems and Clinical
Information Systems)
- Work lists to help employees remember scheduled nursing interventions
- Client documentation produced by a computer
-Computer-based patient records (CPR) and electronic medical records (EMR) - Monitoring tools that
enter measurements and vital signs straight into the patient's electronic medical record
- Critical routes and nursing care plans created by computers
- Automatic billing using nurse documentation for supplies or procedures
- Prompts and reminders that are displayed up throughout documentation to guarantee comprehensive
charting
Nursing Administration (Health
Care Information Systems)
- Automated staff scheduling
- Email for better correspondence
- Analysing costs and trends for budgetary objectives
- Quality assurance and outcomes analysis
Nursing Education - Computerised documentation
- The use of computers to aid in instruction
- Interactive visual technology
- Distance Learning: Web-based degree programmes and courses
- Online sources-CEUs as well as formal nursing degree programmes and courses
- PowerPoint and Microsoft Word presentation software for creating slides and handouts
Nursing Research - The use of electronic searching literature using CINAHL, Medline, and online resources
- The use of NANDA and other standardised terminology for nursing terminologies.
- The ability to identify trends in aggregate data, or information gathered from huge population groups
- SPSS, Statistical Software

9. NURSING INFORMATICS - LIMITATION
• Requirement for a complicated conceptual design process, several
external data bases, employing personnel with experience in
databases, high acquisition costs, programme failures, and highly
dependent operating systems

10. PATIENT RECORDS - PURPOSES
• Medical objectives by enabling direct treatment
• Non-clinical goals to assist with contractual, legal, administrative, and
governance duties
• Innovative and cutting-edge applications of the electronic health
record that
help patients manage their illnesses and overall health and well-being
include risk stratification, remote consultations, clinical decision support
systems, and record access.
• Access to records, which can help people take control of their health
and overall well-being

11. PATIENT RECORDS - IMPORTANCE
• Preserves Valuable Time
• Aids Medical Professionals in Making Accurate Diagnoses
• Identifies the Potential for a chronic Illness
• Reduces Medical Errors
• Determines the Success Probability
• Saves Money on Retests

12. NURSING RECORDS - Importance
Provide baseline data for the plan of action and to evaluate the care given
Nursing records are used for diagnostic purposes. Example: Temperature
graphic record, intake output record etc. can be used for diagnosis.
Evaluate the workload and calculation of manpower required in a
particular setting
Evaluate the quality of care
It can be used for research purposes
It is a valuable document used for legal purposes

13. Principles of Record Keeping
The patient’s records should:
 Be factual, consistent and accurate
 Be updated as soon as possible after any recordable event
 Provide current information on the care and condition of the patient
 Be documented clearly in such a way that the text cannot be erased
 Be consecutive and accurately dated, timed and all entries signed (including any alterations)
 All original entries should be legible. Draw a clear line through any changes and sign and date
 Not include abbreviations or jargons as not all workplaces or organisations will use the same terminology
 Be stored securely and should only be destroyed following the local policy
 Avoid meaningless phrases, speculation and offensive subjective statements/insulting or
derogatory language
 Identify the patient by recording patient’s name, date of birth/age and hospital number on each page of the
record (three approved identifiers) or follow institutional policies on how to identify patient’s records
 Still be legible if photocopied or scanned.

14. Records available in the nursing unit Records available in the nursing office
policies,
Nursing administrative record Nursing administrative records
This includes ward policies, Organisation chart, procedure This consists of hospital policy manual, nursing
manual, stock registers, indent books, list of equipments in use, organisation chart, nursing procedure manual etc.
rotation plan, duty roster, assignment books etc.
admission and discharge books, reports etc.
Personnel records Personnel records
This includes job descriptions, personnel performance record, This includes personal job descriptions of all categories,
cumulative records, personal file and performance file.
It also includes duty related records namely duty roster, roll call
register, allocation and leave forms etc.
Clinical records Patient records
Nursing care plans, nursing notes, observation charts, This includes Hospital report, census book etc.
Temperature Pulse Respiration graphical record, intake output
record, treatment chart etc. are included in clinical records

15. COMPUTERS
• Any device that can be used to compute or compute is referred to as a
computer. It is an electrical device that takes in input, holds onto it for
a while, processes it in accordance with instructions, and outputs
something to the user.
• It's an electronic device that converts data into information.
Computers are highly effective at storing, manipulating, and retrieving
vast amounts of data.

16. USE OF COMPUTERS - HOSPITALS
Patient and medical information
Monitor patients
Studies and research
Inventory
Computers for surgical procedures
Medical equipment and imaging
Communication and telemedicine

17. USE OF COMPUTERS – NURSING PRACTICE
• To quickly access important information about health or illness and treatment plan
• Assists with drug prescription, cross-referencing medications, and entering patient
health information
• Nurses can access patient information from other members of the health care
team, including laboratory test and X-ray findings and health reports.
• For easy access and utilisation by other members of the healthcare team, nurses
can
document patients' health information, treatments, and progress.
• Nurses can get crucial knowledge on nursing diagnosis and care by using computers
to explore nursing practice databases, libraries, and best practice resources.

18. USE OF COMPUTERS – Administration
• Computers assist managers in their work by giving them access to
important information that helps them make decisions.
• It supports the development of the organization's strategic plans for
quality assurance, utilisation reviews, budget and financing, medical
record management, human resources, and facilitation management.
• Schedules for the coming day, week, or month are created using staffing
and scheduling systems

19. USE OF COMPUTERS – Nursing Research
• Computers can be used for problem identification, literature reviews,
research designs, and other stages of the research process.
• They can also be used to assess and identify trends in health issues and
the need for providers with specialised training.
• The advancement of nursing knowledge creation and management is also
possible with computers.

20. USE OF COMPUTERS – COLLEGE
Systematic
Information
Storage
Computerised
Presentations
Simulations
Interactive
Learning

21. USE OF COMPUTERS – COMMUNITY
• A home computer gives high-risk clients access to a range of health-
related information.
• They have the ability to capture information about their health state,
which may then be sent to the central network computer by the healthcare
practitioners.
• In an emergency, the patient can notify base station via a home alert
system.

22. TELEMEDICINE
The delivery of Health Care Services by Healthcare professionals using
Information and Communication Technologies to people living in distant
areas to exchange information for diagnosis, treatment and prevention of
disease and injuries and also for the continuing education, research and
evaluation of Health Care providers to advance the health of individuals and
their communities.
- World Health Organisation

23. TELEMEDICINE - CATEGORIES
• utilisation of remote information and decision analysis resources
to support or guide care for specific patients
• monitoring and tracking of patient status as part of follow-up care or
management of chronic problems
• one-time or ongoing provision of specialty care when a physician is not
available locally
• initial urgent evaluation of patients for triage, stabilisation, and transfer
decisions
• supervision of primary care by non-physician providers when a physician
is not available locally
• consultation, including second opinions

24. TELEMEDICINE - BENEFITS
• Convenience and comfort
• Enhanced remote care accessibility
• Cost-effective option
• Family support
• Prevention of chronic diseases
• Prevents the spread of diseases
• Contextualised assessments

25. TELEMEDICINE - DISADVANTAGES
• technical malfunctions when utilising gadgets
• unable to conduct physical examinations of individuals
• lack of trust and rapport between the patient and the doctor
• lack of access to the required infrastructure, such as high-speed internet
• diagnostic difficulties brought on by poor quality lighting, cameras, or photographs
• difficulties in guaranteeing the security of electronic health records
• lack of clarity on malpractice and liability concerns
• Patients should consult licenced medical professionals in the state in which they
are currently located.

26. TELENURSING - APPLICATIONS
Home care
Case management
Telephone triage
Mental health
Pandemic

27. TELENURSING - BENEFITS
Remote Service
Delivery
Financial Savings
Better Distribution
of Beds
Patient Comfort

28. EMR - Types
Types Description
Departmental EMR Information entered by a single hospital department is departmental Electronic Medical
Record.
Example: Anaesthesia records, operation theatre records, pharmacy systems, radiology
reporting system etc.
Inter-departmental EMR This contains information from two or more hospital departments
Hospital EMR This contains all or most of patients’ medical information from a particular hospital.
Inter Hospital EMR This contains patient’s medical information from two or more hospital
Computerised Medical Record These types of records are created by image scanning of a paper based health record
Personal health record These records are controlled by the patient and contains information at least partly
entered by the patient
Clinical data repository An operational data store that holds and manages clinical data collected from health
service providers

29. EHR - Components
Medical data components
• This consists of referral, present
complaints, past medical history,
physical examination, diagnostic test,
procedures, treatment, medication and
discharge
Nursing data components
• This comprises nursing charting and
nursing care plan; medication
administration, daily charting, physical
assessment and admission nursing notes

30. THANK YOU
Textbook of Nursing Management and Leadership