NURSING INFORMATICS (NCM 111) – SEMI-FINAL TERM
INSTRUCTOR: MS. DOLORES MERCADO
Clinical Practice: Application of Nursing Informatics
Electronic Health Record System
● Often used interchangeable with computerized patient
record, clinical information system, electronic medical
record, and many others.
● Reflects the broader focus on the health of the
consumer or patient.
● Used by all participants in the process of achieving
heath, including all disciplines of clinicians, family
caregivers and the patient.
EHR-s by IOM (Dick, Steen and Detmer, 1991)
● The set of component that form the mechanism by
which the patient record are created, used, stored and
retrieved.
● A patient record system is usually located within a
healthcare provider system.
● It includes people, data, rules and procedures,
processing and storage devices (e.g. paper and pen,
hardware and software) support facilities.
EHR-s 2003
● Longitudinal collection of electronic health information
for and about persons, where health information is
defined as information pertaining to the health of an
individual or healthcare provided to an individual.
● Immediate electronic access to person and population
level information by authorized and only authorized
users.
● Provision of knowledge and decision support that
enhances the quality, safety, and efficiency of patient
care.
● Support of efficient processes for healthcare delivery.
Goal of EHR-s
INFORM CLINICAL PRACTICE
● Informing clinical practice is fundamental to improving
care and making health care delivery more efficient.
● This goal centers largely around efforts to bring EHRs
directly into clinical practice.
● This will reduce medical errors and duplicate works,
and enable clinicians to focus their efforts more directly
on improved patient care.
INTERCONNECTING CLINICIANS
● Will allow information to be portable and to move with
consumers from one point of care to another.
● Will require an interoperable infrastructure to help
clinicians get access to critical healthcare information
when their clinical/ or treatment decisions are being
made.
PERSONALIZED CARE
● Consumer-centric information helps individual
manage their own wellness and assist with their
personal healthcare decisions.
● The ability to personalized care is a critical
component of using healthcare information in a
meaningful manner.
IMPROVE POPULATION HEALTH
● Population health improvement requires the
collection of timely, accurate, and detailed
clinical information to allow for the evaluation
of health care delivery and reporting of critical
findings to public officials, clinical trials and
other research feedback to clinicians.
Dependable System for Quality Care
● Dramatic Transformation- from inefficient, costly,
manually intensive, crisis-driven model of care
delivery to more efficient, consumer- centric, science
based model that proactively focus on health
management.
● Driven by skyrocketing cost of healthcare; exposure
of patient safety problems, aging population— IT.
● ICN Code of Ethics for nurses affirms that the nurses
“holds in confidence personal information” and
“ensures that use of technology (is) compatible with
safety, dignity, and rights of people”.
● Fulfilling these ethical obligations is the individual
responsibility of the nurse, who has the ability and
authority to ensure that personal information is
protected and technology is safe.
● Dependability- is a measure of the extent in which
system can justifiably be relied in to deliver the
services expected from it.
Attributes of Dependability
● System reliability- consistently behaves in the same
way.
● Service availability- requires services are present
and usable when they are needed.
● Confidentiality- sensitive information is disclosed
only to those authorized to see it.
● Data integrity- data are not corrupted or destroyed.
● Responsiveness- the system responds to user input
within an expected and acceptable time period.
● Safety - the system does not cause harm.
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 NURSING INFORMATICS (NCM 111) – SEMI-FINAL TERM
INSTRUCTOR: MS. DOLORES MERCADO
Guidelines for Dependable System
● Architect for Dependability- An enterprise system
should be developed from the bottom up so that no
critical component is dependent on a component less
trustworthy that itself.
● Anticipate Failures- Features that are transparent to
software applications should be implemented to
detect faults, to fail over to redundant components
when faults are detected and to recover from failures
before they become catastrophic.
● Don’t be adventurous- One should use only proven
methods, tools, technologies, and products that have
been in production, under conditions and at a scale
similar to the intended environment.
8 Administrative Safeguards: Important Operational
Practices
● Security management, including security analysis and
risk management
● Assigned security responsibilities
● Information access management, including isolation
of clearinghouse functions from other clinical
functions.
● Security awareness and training
● Security incident procedures, including response and
reporting
● Contingency planning, including data backup
planning, disaster recovery planning, and planning for
emergency mode operations.
● Evaluation
● Business associate contracts that lock in the
obligations of business partners in protecting health
information to which they may have access.
Physical Safeguard
● Access control, including unique user identification
and an emergency access procedure.
● Audit control
● Data integrity protection
● Person or entity authentication
● Transmission security
Nursing Minimum Data Set System
● A standardized approach that facilitates the
abstraction of these minimum, common, essential
core data elements to describe nursing practice from
both paper and electronic records.
● Intended for use in all settings where a nurse provides
care.
NMDS Data Element
Nursing Care Element
● Nursing Diagnosis
● Nursing Interventions
● Nursing Outcomes
● Intensity if nursing care
Patient or client demographic element
● Personal Identification
● Date of birth
● Sex
● Race and ethnicity
● Residence
Service Elements
● Unique facility or service agency number
● Unique health record number or patient or client
● Episode admission or encounter date
● Discharge or termination date
● Disposition of patient or client
● Expected prayer for most of this bill
Benefits of the NMDS
● Access to comparable, minimum nursing care and
resource data on local, regional, national and
international level.
● Enhanced documentation of nursing care provided
● Identification of trends related to patient and client
problems and nursing care provided.
● Impetus to improved costing of nursing services
I-NMDS
● Internationally relevant, essential, minimum data
elements to be collected in the course of providing
nursing care.
● These information can be utilized to describe,
compare, and examine nursing practice around the
globe.
● Composed of (1) representative of the National
Nurses Association (ICN) (2)
International Medical Informatics Association Nursing
Informatics Special Interest Group
(3) Informatics Experts.
I-NMDS: Purposes
● Describing the human phenomena, nursing
interventions, care outcomes, and resource
consumption related to nursing services.
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 NURSING INFORMATICS (NCM 111) – SEMI-FINAL TERM
INSTRUCTOR: MS. DOLORES MERCADO
● Improving the performance of health care systems
and the nurse working within these system worldwide.
● Enhancing the capacity of nursing and midwifery
services
● Addressing the nursing shortage, inadequate working
conditions, poor distribution and inappropriate
utilization of nursing personnel, and the challenges as
well as opportunities of global technological
innovations.
● Testing evidence based practice improvement
● Empowering the public internationally
Netiquette Rules and Guidelines
POLICY AREA: Netiquette Policy and Guidelines for Nurses
● "Netiquette", or internet etiquette, is the code of common
courtesy for users of the Internet.
● One should always use this courtesy when participating in
e-mail communications, discussions, chat rooms, blogs,
and all other types of computer communication.
● Internet users should learn the rules of proper netiquette
to avoid offending others with violations of courteous
Internet communication.
● Netiquette rules may vary slightly when one is engaging in
personal communications with a close friend, or whether
this individual is composing a professional electronic
communication to be viewed by others at work.
● Nurses engaging in professional electronic
communications with other health care professionals
and/or patients should learn and understand this form of
etiquette.
Why Should Nurses Use "Netiquette"?
● Nurses are in an occupation where a strict code of
professional conduct is important for both the nurse and
the profession as a whole.
● In order to advance the nursing profession and promote
nurses as professionals, these health care workers should
engage in a professional manner in all methods of action
and communication.
● One area of particular importance is electronic
communication via the Internet, Intranet, or organizational
electronic mail.
● When one uses this method of communication, he or she
may forget to use the traditional grammar, punctuation,
and simple etiquette rules established for more traditional
means of interaction.
● In this manner, the idea of "netiquette" provides
individuals, such as working professionals, with a standard
of etiquette that is specifically designed for the electronic
communication methods used by numerous individuals
today.
The Standards of "Netiquette"
● Thinking and revising before posting an electronic
communication.
● One should remember that a real individual is reading the
sent message.
● Include the recipient’s name, a greeting, closing, and
signature.
● Keep electronic messages short and to the point.
● Reply to messages promptly and be honest and respectful
in all messages.
● It is important to note that the intended recipient may not
be the only person reading the electronic message, so one
should avoid judgments and assumptions.
● One should never assume that any communication sent
from a work computer is private.
● One should avoid using common “net speak” acronyms
and abbreviations when writing electronic
communications to others
● Although some individuals are familiar with these “net-
speak” abbreviations, other persons may misunderstand
the intended meanings of these abbreviations. It would be
better to spell out the entire word or phrase to avoid
confusion and even offense.
● It is important to note that netiquette rules apply not only
to communication via computer.
● One should use these standards when communicating via
electronic devices such as PDAs, and cell phone electronic
mail.
● If one should find that an individual who has sent an
electronic communication has committed a serious
netiquette violation, one may wish to politely correct this
individual.
● By correcting the problem immediately, one can educate
this individual and keep his/her from making another
violation.
● If one feels that a correction is in order, one should send a
private e-mail to this individual as to avoid
embarrassment.
● One might include the netiquette infraction as well as the
proper netiquette technique.
POLICY AREA: Netiquette Policy and Guidelines for Online Class
Students must recognize that entering into an online
classroom is in fact a classroom and certain classroom conducts are
expected when communicating with peers and facilitators. These
guidelines for online classroom conduct and interaction are known
as netiquette.
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 NURSING INFORMATICS (NCM 111) – SEMI-FINAL TERM
INSTRUCTOR: MS. DOLORES MERCADO

A. Security: 2. Take your posts seriously and review and edit your posts
The email password and course code are very important security before sending.
features in an online class. 3. Be as brief as possible while still making a thorough
1. Do not share email password and course code to anyone. comment.
2. Change your email password if you think someone else 4. Always give proper credit when referencing or quoting
knows it. another source.
3. Always log out when you are finished using the online 5. Make sure to read all messages in a thread before replying.
platforms. 6. Not repeat someone else’s post without adding something
from his/her own opinion.
B. General Guidelines:
7. Avoid short, generic replies such as, “I agree.” The student
When communicating online, you should always: should include why he/she agrees or add to the previous
1. Treat the faculty and classmates with utmost respect in point.
email or any other means of communication used in the
8. Always be respectful of others’ opinions even when they
online class. differ from your own.
2. Always use your professors’ proper title: Dr. or Prof., or if 9. Express differing opinion in a respectful and non-critical
in doubt use Mr. or Ms. way.
3. Use clear and concise language. 10. Not make personal or insulting remarks.
4. Observe correct spelling and grammar. This include 11. Be open-minded.
postings and discussions in the Google Classroom stream.
5. Avoid slang terms such as “wassup?” and texting
abbreviations such as “u” instead of “you.” 6. Use
standard fonts such as Cambria, Calibri or Times New
Roman and use a size 12 font
7. Avoid using the caps lock feature, as it can be interpreted
as yelling.
8. Limit and possibly avoid the use of emoticons.
9. Be cautious when using humor or sarcasm. Tone is
sometimes lost in an email or discussion post and the
message might be taken seriously or sound offensive.
10. Be careful and cautious of posting or uploading personal
information.
11. Do not send confidential information via e-mail.

C. Email Netiquette
When sending an email to the faculty and classmates, the student
should:
1. Use a descriptive subject line.
2. Be brief.
3. Make sure that when you send attachments, the recipient
can open it.
4. Sign the message with your name, course, year level, and
college/department.
5. Be careful and cautious of sending e-mail to more than one
person.

D. Stream Netiquette and Guidelines

When posting on the classroom stream, the student should:
1. Make sure to post only the information or materials that
are relevant to the topic and within the scope of the
course.

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