Management of Care / 07

Make sure to:

  • Be able to effectively receive, verify, and implement orders from healthcare providers effectively.
  • Document the care provided to all clients promptly and comprehensively.
  • Use various online resources for both clients and in nursing practice.

Consider the emotions of the healthcare team when they discovered that the surgeon had operated on the wrong side of a client or, in some instances, even on the wrong client. Additionally, registered nurses have expressed concerns about the difficulty of deciphering the orders written by healthcare providers for their clients and the considerable time required to contact them for clarification. Moreover, there have been instances where clients faced delays in consultations due to misfiled medical records or charts. Finally, clients received healthcare services virtually via telehealth during the COVID-19 pandemic. Such challenges underscored the need for the integration of information technology in healthcare settings.

In this learning experience, the learner will explore the influence of information technology on nursing care and practice. Specifically, the learner will gain insights into healthcare providers’ orders, documentation, and using various online resources for both clients and within nursing practice.

2.1 Healthcare Providers Orders

Clients must receive treatment for their specific medical conditions to facilitate recovery or achieve optimal health. To achieve this goal, healthcare providers, such as physicians write orders for clients. These may include radiologic and laboratory tests, medications, or restraints. While radiologic tests assist in diagnosing conditions, laboratory tests help identify problems and assess treatment efficacy. Medications address both acute and chronic conditions, and restraints are sometimes deployed for client safety. Registered nurses bear the responsibility of receiving, verifying, processing and/or implementing these orders from healthcare providers.

Information technology, or advanced technology, has revolutionized how registered nurses obtain and process orders to provide care for their clients. Automated orders and electronic health records have relegated paper-based methods to obsolescence. Consequently, registered nurses no longer need to struggle with deciphering unreadable handwriting. However, it also mandates thorough scrutiny to ensure clarity, completeness, and client understanding of the orders (Burke, 2023a). Furthermore, registered nurses should verify the accuracy of the information and ensure the order's alignment with care standards and facility guidelines.

To maintain accuracy and safety in medication administration, it is crucial to verify that medication doses do not contain a zero before or after a decimal point. Additionally, certain terms, such as "unit," "international unit," "every other day," "at night," "morphine sulfate," and "magnesium sulfate," should not be abbreviated (Burke, 2023b). According to Burke (2023a), medications should only be administered given the presence of the following data:

  • Medication Name
  • Dose
  • Form
  • Route
  • Frequency
  • The reason for requesting the medication
  • Signature of the healthcare provider who ordered the medication

Before utilizing a restraint, please refer to the healthcare facility’s policies. Burke (2023a) stipulates that a restraint order should encompass:

  • Reason(s) for the restraint.
  • Type of restraint.
  • Duration of restraint use.
  • Client behavior justifying the restraint’s application.
  • Signature of the healthcare provider authorizing the restraint use.

2.2 Documentation of Care given to Clients

Registered nurses ensure continuity in client care by documenting their services in electronic health records, the modern replacement for traditional paper medical records. One must never alter, fabricate, erase or access medical records unless they pertain to clients under one’s care (Burke, 2023b).

Documentation adheres to a system set by the healthcare facility. Table 1 provides insights into various forms and methods of documentation.

Table 1

Examples of Medical Records and Documentation Types

Adapted from Burke, A. (2023b). Integrated Processes: NCLEX-RN. https://www.registerednursing.org/nclex/integrated-processes/#nursing-process

 

2.3 Data Resources for Client and Nursing Care

Before technological advancements, health information and clinical resources were chiefly available through print materials such as journals and books housed in libraries. Bulky binders contained facility-specific policies and procedures. Advances in technology have made this same information more easily accessible online via smartphones, tablets, iPads, laptops, and desktop computers. It is important to obtain accurate and reliable data, which can be found from websites whose URL ends with “.edu”, “.org”, and “.gov” (Burke, 2023a).

Clients can access online resources, such as the Merck Manual for Home Use. Additionally, national organizations such as the American Cancer Society and the American Heart Association offer disease-specific information. Table 2 provides an overview of some databases that can assist in providing evidence-based nursing care and serve as resources for clients.

Table 2

Overview of Client and Nursing Care Resources

Adapted from Burke, A. (2023a). Information Technology: NCLEX-RN. https://www.registerednursing.org/nclex/information-technology/

A comprehensive grasp of information technology's role in healthcare is crucial for nurses. This insight enhances capabilities in acquiring orders from healthcare providers, document nursing care in electronic health records, and leveraging evidence-based online resources for clients and clinical practice.

The provided resources bolster one's understanding of information technology, promoting proficiency and aiding in the prevention of medical errors. Facilitating success on the NCLEX examination and excelling in clinical practice keep being the goals.

After reviewing the resources, discern areas needing refinement and focus your attention there.

  • Burke, A. (2023a, September 23). Information Technology: NCLEX-RN. https://www.registerednursing.org/nclex/information-technology/
  • Burke, A. (2023b, September 14). Integrated Processes: NCLEX-RN.  https://www.registerednursing.org/nclex/integrated-processes/#nursing-process
  • Kaplan Nursing. (2023). Next Generation NCLEX-RN Prep 2023-2024: Practice Test + Proven Strategies (9th ed.). Kaplan Test Prep.

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