Nursing Informatics Standardized Data Entry Discussion

Review Informatics Strategies & Tools to Link Nursing Care with Patient Outcomes in the Learning Health Care System from the American Medical Informatics Association (AMIA) about linking informatics strategies to patient outcomes. 

Respond to the following 

How does standardized data entry relate to improving patient safety and improved care outcomes? 

Provide examples from your own clinical practice (labor & delivery). 

TWO response posts 

Here is ONE response post I need with 175 words.Standardized data entry is essential to improving patient safety and patient care outcomes. By using a standardized data entry system, all participants in the patient’s care will be able to contribute and review important information. This can help to avoid unnecessary wasted time, testing, and money. This helps create well-informed providers and reduce duplication in testing which streamlines a patient’s care across the spectrum saving time and money. Patients have immediate access to their records as well allowing them to better participate in and advocate for their healthcare.When a patient comes into the emergency department, time is of the essence and the patient may not be able to tell you about their health history. They may be unresponsive or have a history of Alzheimer’s. If we can identify the patient, we can open their chart and see their history, lab results, imaging results, recent surgeries and procedures, and notes from all healthcare professionals involved in the patient’s care. We can determine if there is a DNR/DNI in place and respect the patient’s wishes and cease resuscitation efforts. When a patient arrives by ambulance in to the emergency department unresponsive, the information obtained from standardized data entry can help the medical team to assume treatment more quickly to save tissue and life. We can determine the likelihood of overdose vs myocardial infarction vs pulmonary embolism more quickly combining the current signs and symptoms with information gathered from the record. We can initiate more specific treatment faster than if we had no information at all. My emergency department is located in a tourist location. We care for many patients that are on vacation. It is evident how important standardization is when we take care of these patients. They may come from an area that uses a different EMR from our system and we are unable to access their information. Their chart is a blank slate. “To be useful, data and information must be available when needed, to whom it is needed, and in a form that can be analyzed or used” (Hebda et al., 2018, p. 25).Hebda, T. L., Hunter, K., & Czar, P. (2018). Handbook of informatics for nurses & healthcare professionals, 6/e (6th ed.). Pearson Education.

Here is the SECOND response post.Standardized nursing language is necessary because it ensures better communication among nurses and other health care providers, hence influencing health outcomes on patients’ recovery. Moreover, another reason standardized nursing language is essential is that it increases the visibility of nursing interventions where the medical staff efforts can influence positive health outcomes in their client’s recoveries in the hospital (Adubi, Olaogun & Adejumo, 2018). Also, standardized nursing language makes the nursing staff improve patient care, hence influencing the health outcomes of their clients who are undergoing treatment plans in the hospitals. Furthermore, it enhances data collection to evaluate nursing care outcomes, resulting in improved health care. Greater adherence to care standards will ensure positive health care outcomes for patients who seek medical assistance in hospitals. Standardized data entry and the advantages of health information technology (HIT) include its ability to store and retrieve data; the ability to convey patient information effectively in a legible format; improved protection of medications by greater legibility, which could minimize the likelihood of prescription errors; and the ability to retrieve patient information easily and provide patient safety and care outcome by meeting the priorities of improving patient safety and treatment. By implementing electronic documentation to measure clinical competence hospitals can examine the following: whether nurses are documenting accurately, documentation is structured in a coded format and can indicate whether the data has integrity. Also, it measures if nurses can pull out data needed to engage in clinical decision-making; indicate the right things that nurses need to do and if they do them or does a nurses’ documentation and their patients’ corresponding outcomes suggest that he/she is practicing at height of their license. Lastly does the documentation of each individual nurse support building linkages between nursing care and patient outcomes? (AMIA.org)