A nurse is a health care professional who is engaged in the practice of nursing. Nurses are responsible—along with other health care professionals—for the treatment, safety, and recovery of acutely or chronically ill or injured people, health maintenance of the healthy, and treatment of life-threatening emergencies in a wide range of health care settings. Nurses may also be involved in medical and nursing research and perform a wide range of non-clinical functions necessary to the delivery for health care. The nurse should have the knowledge of computers.
Computers in nursing: In this book I have covered computer application and system that can be used by nurses. Nowadays few package software programs are available for nursing application. The nurse should think of more creative ways of using a computer to solve nursing problems.
Nurses became very involved in designing and programming nursing information system. After ten year even if all these technologies change nursing advices will remain in use. This scenario is a step further and all this information could be made available to the ordinary public in the form of a tiny medical reference chip. Nurses must balance its high tech with high touch. According to Naisbitt's theory, whenever new technology is introduced into society there must be a counterbalancing human response that is high touch or else the technology will be rejected.
The future of computer use by nursing staff is exciting. The technology is moving so fast that there is no way to predict how nurse will be using the computer as a tool for patient care in the future.
Computers are the pillars on which any organization works in present day. Today, computers are playing a vital role in helping many hospitals and nursing staff with a variety of responsibilities. But hospital computerization is a relatively new phenomenon and newer one for hospital nursing departments involved with patient care.
Multi Speciality Clinics/Hospitals
In such set-ups, the system schedules appointments for more number of patients a year according to the availability of doctors within hospital for consultation.
A similar clinic program SYSTEM RX that manages patient billing, account receivable, insurance, payroll and accounts payable. It is also schedules appointment, reminds users of important events and participates in similar related administrative functions. SYSTEM RX can also generate reports on demand which is a function commonly called adhoc reporting.
Community Health Nursing
Computers are used in community health both in public health sector and private health care. Many ambulatory care settings and country health care sectors all over the country have contributed to development of computer technology for the community health nursing.
Computer Stored Ambulatory Record (COSTAR) was developed by the Laboratory of Computer Science at the Massachusetts General Hospital for the Harvard Community Health Plan.
Another important computer system employed is the use of Vermont at the Champlain Island Rural Health Initiative Project. It uses the computerized problem-oriented medical information system known as PROMIS developed by Dr Lawrence Weed of the University of Vermont, this system employs microwave transmission from the laboratory in Burlington to the health center on Champlain Island for guiding the nurse practitioner staff in the application of primary health care in an isolated rural area. Nurse practitioners using the problem-oriented client record receive physician-approved protocols, medical and nursing information and guidelines for health maintenance and client education through a computer terminal.
The Indian Health Service also uses computers, specifically an online Patient Care Information System (PCIS), that contains all health care data for residents of the Papago Reservation in Tucson, Arizona. Before making visits to the reservation, the community health nurses can access the prior medical records by using a computerized microfiche printout of previous medical and nursing health care visits.
DATA CONFIDENTIALITY, PRIVACY AND SECURITY
New scientific breakthrough is not without problems and along with this new technology come the problems of confidentiality, privacy of patient records and hospital liability if patient data is wrongly disclosed or misused. A review of laws clearly show that both the health care sector and the medical professionals to term it as its ethical responsibility to keep the medical information given to them confidential.
Security means protecting information from accidental or intentional access by unauthorized people from unauthorized modification and from unauthorized accidental or intentional destruction. Computer systems are installed in hospitals and personal involved must initiate and participate in evaluations of privacy protection. Nurses are the largest group of computer system users in any hospital and they are keepers of confidential patient information protectors of patient privacy and ensure that system security measures are followed. This is not incompatible with the duties, trust and responsibilities that a nurse normally exercises in daily patient care, even in facilities without computer systems.
Here are some guidelines concerning computer system security currently being followed by most hospitals and other health care institutions.
- Individual passwords and sign-on identification is essential. Sign- on-identification and passwords are codes that identify each user and link him or her with the computer functions needed to perform the job.
- Access to terminal should be controlled. Nurses should have access to terminals only on the nursing unit.
- As hospital personnel leave the employment there should be a method for immediately removing the sign-on-and password codes from the system.
- When developing security policies and procedures, system designers must be concerned with the patient privacy.
- The system and its security controls need to be reviewed at regular intervals by a security co-ordinator.
- All personnel who use the system must be educated on the importance of patient confidentiality.
The confidentiality of patient records is more likely to be protected when the data is stored on a computer.
Nurses need to participate in the selection, design, implementation and training for the use of the system. Whether they work in a hospital, community health center, education or clinic, nurses need to be involved in computer application. If they are not, decisions will be taken without them. To be able to participate in decisions, nurses need to know about computers.
Achieving information literacy is dependent on being computer literate, since computer technology is used to access information. Computer literacy requires more than being able to use computers to find information. The computer-literate health care provider must possess a basic understanding of computer hardware, of the common types of software and of the different ways in which software application can be used. In addition to this foundational knowledge about computer technology, computer literate health care provider should know how to use the particular computer systems and application found in their workplace. They should also aware beacuse and should able to evaluate potential or evolving computer application that may be suitable to their workplace. As computer technology and its application develop over a period of time, the computer literate health care provider must be committed in keeping up with change through lifelong learning.
To be a Computer Literate they should know
- What a computer system is and does?
- The role played by hardware and software in a computer system.
- The distinction between types and levels of hardware and software.
- The role of data in a computer system.
- The basic techniques of organizing and managing data for input, output, storage and use.
- How a computer system can be used?
- The limitations and range of costs involved in that use.
- Basic computer terminology.
Thus in order to participate in the computer technology that affects nursing, nurses must become computer literate and keep abreast of changes in the practice of their profession.
Nurses use computer for a variety of functions, they can be categorized into following areas.
Patient Classification and Staffing Requirement
- Education and research
Further computer can help with staffing requirements in three ways:
- They can classify patients that are categorized according to some assessment of their nursing care requirements for a specified period of time.
- Computer can translate patient care needs into the number of nurses required so that the set number of nurses could be provided. This process called staffing includes determining shift by shift the need for nurses provided on the acuteness of patient as shown in the patient classification.
- Computers help schedule the nursing staff, which is to list out nurses on a day-to-day basic.
Staff and scheduling: Staffing includes scheduling the master schedule and updating based on patient and staff requirement. Staffing also includes determining on a shift-by-shift basis the need for nurses based on the activity of the patients. Part of the staffing process is to call the staffing office for additional help when sick calls and vacations leave a unit understaffed.
Computerized Classification System
Two basic options are available when acquiring a classification staffing and scheduling system:
- The first is contract for in-house system development with the hospitals computer service department. Because of the unique requirements of their existing classification, staffing and scheduling systems some hospitals select in-house system development rather than adapting their present system to a commercial package.
- The other option is to purchase a software package from a vendor. This system utilizes a computer and some can be integrated into an existing in hospital information system.
The patient classification systems that run on computer do not solve staffing problems but they do provide a means allocating personnel to meet daily patient care needs.
Scheduling with Computers
Scheduling is another way in which computers can help nurses. Prior to the usage of computers, the head nurse would take a list of the names of all nursing unit employees and their request for days off for the next schedule cycle and start the tedious process of creating another schedule.
- Nurses cover the entire unit.
- Nurse needs to work only 6 days per week.
- Nurse has every weekend.
Patient information: Nursing manager is responsible for reviewing the quality of patient care. A nurse round, that is walking from bedside to bedside looking at patient and reviewing the care they are receiving were the traditional means of accomplishing this goal.
This information can include patient census by unit with diagnosis acuity classification, special diagnostic or surgical procedure or whatever information nursing managers believe is necessary in monitoring the quality of care delivered.
Employee information: Nursing administration is responsible for maintaining files on each employee. To be certain that the employee benefit program is being managed properly and ascertain that all required records are current. The computer can help maintain these files including the following:
- Alpha index of employee
- License verification
- Performance evaluation
- In-service education
Nursing care plan: The care plans are a permanent part of the patient record. Computerized nursing care plans benefit such as:
- Reduce the time required to generate the care plans
- Congruence with JCAH requirements
- Ability to use the nursing process and nursing diagnosis both of which the newer graduate have learned in school
- More care plans prepared and completed
- Follow-up with patients who are involved in their own care and setting their own goals
- Potential for individualization and updating as necessary without typing and retyping.
Nurse assessment: Computer application helps nurse plan. To implement nursing care and generate the following forms:
- Current orders summary
- Daily orders summary
- Medical care plan
- Weekly mediation survey
- Nursing records: In nursing records the following are taken care:
- Admission nursing note
- Nursing assessment
- Nursing care plan
- Documentation against the nursing care plan
- Revised nursing care plan
- Discharge nursing care plan
- Nursing record at discharge.
Administrative application: There are eight major management functions such as:
- Planning: How to do? When to do?
- Organizing: Lead the program
- Staffing: Recruit, promotion, depromotion
- Directing: Setting vision, command
- Coordinating: Interaction with other department with good manner
- Controlling: Supervision
- Budget: repare the budget based on income and expenditure
- Budget preparation: Budget preparation which is used to include long hours of speculating calculating and predicting is no longer needed. A spreadsheet or any application software can be developed to complete all phase of the capital personnel and supply and expense budget. Thus, budgeting is made easier through computers.
- Report: Send feedback
- Audit: Verification.
Probably the most overlooked and underappreciated resource in the operating room which nursing professionals require is nursing software that performs multiple services. It minimizes non-clinical time, improves time management and facilitates access to information, allowing them to do the job they were trained to do that is to deliver patient care. Nursing software is easy to use and helps to reduce operating cost and improves inefficiencies.
Some important software listed below:
1. SIS Nursing Software
SIS nursing software includes a series of modules that address each nursing related phase of the surgery case and more.
SIS nursing software modules include the following:
This software consists of documents of all data gathered in patient screenings and interviews prior to the day of surgery.
This software collects and records pre-surgery information on the actual day of surgery about nursing assessments, medication history, pre-existing conditions, prior anesthesia and surgical history, family history, lab results, and more.
This software provides complete electronic patient record for surgery.
Personalizes screens to fit your hospital's current documentation standards.
This software captures information on procedures, personnel, material usage, all case times, counts, diagnosis, drugs, and every event or action that occurs during a case.
This software utilizes special modular options for Cardiovascular, Pediatric, and Same Day cases. Thus, the system matches the special needs of these case types.
Postoperative or PACU
In this software, we get document recovery scores, material usage, criteria-based discharges, drug responses, surgical return statistics, vital signs, pain score calculations, and all other important data following surgery.
This software measures post-surgery outcomes.
Devises and administers surveys for Quality Assurance purposes.
“Chart by exception” is a device by which the push of a single button models are established. Clinical Pathways, default values, timed events, specific fields, etc. can be selected with a single keystroke.
Health Care Information Solutions offer an exclusive suite of integrated applications to satisfy complete requirements of the following industries.
- Nursing homes
- Skilled care homes
- Veteran homes
- Long-term care facilities
The turn key packages manage the following critical areas of health care organizations.
- Patient census/administration
- Patient billing/Accounts receivable
- Patient funds
- MDS/Care plan/Medical charting
- General ledger/Accounts payable/Payroll
- Administrative staff scheduling.
- Create, manage, track, and electronically submit your MDS assessments with no hesitation
- Bill all payers including Medicaid and Medicare with HIPAA compliant electronic bills
- Manage patient accounts, patient funds, budgets, ancillary charges, therapy tracking, and more
- Print patient and vendor checks
- Establish a full staffing schedule in minutes
- Track vacation and sick time, as well as certification timetables
- Estimate budget and labor costs so you are aware of the bottom line
- Enables effortless staffing to keep things quick and easy.
2. MDS Clinical Package
Health Care Information Solutions, MDS Ease Clinical Package is the perfect solution for nursing homes looking for an answer to the tedious and time consuming MDS process.
With the MDS Ease Clinical Package, accounts for all your patients and their assessment records will be maintained, while allowing you to create new assessments with unprecedented ease. Rugs scores will be automatically generated for you and when ready, all your validated assessments are batched and added to a HIPAA compliant file, ready for submission.
Care plans are also generated for the patients judging by their individual assessments. You can maintain and update the patient's care plan as the patient progresses.
MDS Ease also comes equipped with advanced security features. Users can be granted or denied access to certain parts of the software, giving the users greater focus on their specific departments.
Like all Health Care Information Solutions software, MDSEase can be installed as a stand alone application or in a network environment.
Health Care Information Solutions MDSEase Clinical Package is guaranteed to meet all clinical needs with ease.
Microsoft Health care Users Group, Inc. (MS-HUG) provides a health care industry forum for exchanging ideas, promoting learning and sharing solutions for information system using Microsoft technologies. MS-HUG uses this forum to provide industry leadership, drive appropriate standards and develop associated requirements in support of health care solutions. MS-HUG is not affiliated with Microsoft Corporation. It is an independent, non-profit organization catering to the needs of information systems developer and users in the health care industry.