Chapter 8: Documentation and Informatics

Chapter 8: Documentation and Informatics

Identification: AMBP020v2019c08
Expiration Date: December 31, 2023
Credits (Post Test and/or Evaluation Required)
Available until 12/31/2023
  • 1.50 - CH


Continuing Education Instructions and Disclosure Information:

  • Contact hours available until 12/31/2023.

Requirements for Successful Completion:

  • Complete the learning activity in its entirety and complete the online CNE evaluation. You will be able to print your CNE certificate at any time after you complete the evaluation.

Faculty, Planners, and Authors Conflict of Interest Disclosure:

  • There are no disclosures to declare

Commercial Support and Sponsorship:

  • No commercial support or sponsorship declared

Accreditation Statement:

  • This educational activity is jointly provided by Anthony J. Jannetti, Inc. (AJJ) and AAACN.
  • Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
  • AAACN is a provider approved by the California Board of Registered Nursing, provider number CEP 5366.

Learning Outcome:

  • After completing this learning activity, the learner will be able to describe how informatics and electronic records support safe, efficient clinical care, and enable quality monitoring, research and care evaluation.

Learning Engagement Activity:

  • Clinical decision support tools and alerts are increasingly being built into electronic health records. Do nurses in your ambulatory work setting utilize clinical decision support tools? How effective are these tools? Are there other tools that, if available, would improve clinical care?

Note - only CE Evaluations are available online.

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Chapter 8: Documentation and Informatics

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Sarah Sylvia
2/7/23 9:34 pm

In my ambulatory infusion center, I use the epic system and there are many clinical decision support tools that I use. The epic system has a falls tool that when filled out alerts you to those that would be a falls risk in the unit based on a numbers score. There are interventions that can be implemented based on this high falls score. This alerts the nurse who is at the greatest risk and how to prevent injury in the unit. We have a tool in the medication administration area that alerts you when recording a patient weight whether the patients weight has changed by 10 %. Most of the medication that I give are weight based, so this would alert me to a change from last admission prompting some more investigation and a call to pharmacy. This helps to prevent error in medication administration based on weight. It would be helpful for the ambulatory nurse to identify more risks based on assessment and current data about the patient to help predict potential negative outcomes. Having early warnings by using data in the chart may help the nurse to be prevent illness and hospitalization through better education and proactivity in patient care. I would like to see an increase in the use of predictive software in order to identify patients that do not show up for appointments which may lead to advanced illness. Having this information could help the office nurse to put measures in place to prevent no shows.

Jamie Hillsberry
5/15/23 2:30 pm

The hospital I work for uses the Epic system. The Epic system can be user friendly and challenging at the same time. This system does have many built in support tools that nurses use on a daily basis, depending on which unit they work in. Some support tools that Epic gives us include: a falls tool, skin assessment tool with an Avatar, a delirium tool, sepsis tool, and a blood transfusion tool to name a few. Additionally, because I work in an infusion center many of our medications that we give are weight based. I find Epic is very helpful when entering a patient's weight. If a patient has had a significant decrease and increase in their weight there is an alert that reminds the user there has been a change in weight percentage. I find this extremely helpful because if the current weight is incorrect then the patient wouldn't receive the correct dosage of medication. These types of tools are very helpful and I feel can prevent many errors and helps us keep our patients safe. Lastly, another nice built in alert tool would be for a medication if a patient is allergic to a specific medication or has already had an infusion recently and that it may be too soon for another infusion. All very important tools in managing our patients, their infusions, and most importantly keeping them safe.