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NATIONAL AMERICAN
BLOOMINGTON CAMPUS

UNIVERSITY
BSN PROGRAM

Nursing 4145: Holistic Nursing Care in Acute Illness II and End of Life Clinical
Learning Plan 1
Orientation
Computerized Information System (CIS)
Organizational structure, mission, vision, philosophy and values
Objective of the Course:
Upon successful completion of this course, the student will be able to:
7. Apply basic organizational and systems leadership in the delivery of safe, competent, and
culturally congruent quality nursing care to clients in the emergent and/or acute care
setting.
Knowledge and skills leading to mastery of this competency:
d. Examine basic organizational structure, mission, vision, philosophy and values.
8. Demonstrate skills in using patient care technologies, information systems, and
communication devices that support safe nursing practice.
Knowledge and skills leading to mastery of this competency:
a. Use standardized terminology in a care environment that reflects nursings unique contribution
to patient outcomes.
b. Understand the use of CIS systems to document interventions related to achieving nurse
sensitive outcomes.
c. Apply safeguards and decision making support tools embedded in patient care technologies
and information systems to support a safe practice environment for both patients and healthcare
workers.
d. Recognize the role of information technology in improving patient care outcomes and creating
a safe care environment.
e. Advocate for the use of new patient care technologies for safe, quality care.

Overview:
Nurses must know how to record and report data and information and to think critically, applying
knowledge to use information for client care. Many hospitals use nursing information systems to
support the documentation of nursing activities and provide resources for managing nursing care
delivery. Nursing informatics is vital in helping nurses make rapid and accurate decisions about
patient care. As a nurse, it is essential that you know how to use the clinical databases within
your institution and apply information to ensure that high-quality, appropriate client care is
delivered.
Learning Activities:
Computer orientation
Specific clinical site orientation
Facility and unit tour
Review:

Guidelines for Reflective Journaling Handout 1


Clinical site specific handouts
http://www.uta.edu/ced/static/onlinecne/CEAugust08.pdf

Come to class prepared to discuss:


o Organization structure, mission, vision, philosophy and values
o Identify how informatics is being used in their clinical setting. For example,
patient care database and classification systems, nurses notes, or electronic
medical records, computerized medication delivery systems may be present in
your clinical facility. Consider who has access to the system, who can change and
enter information, and what the implications are of nursing students having access
to the system. Discuss how patient privacy can be maintained.
o Share experiences with the use (or unavailability) of the electronic medical record
Post-class:
Reflective Journal
Learning Objectives
1. Identify purpose of health care record.
2. Identify methods to maintain confidentiality of records.
3. Describe the five quality guidelines for documentation and reporting
a. Factual
b. Accurate
c. Complete
d. Current
e. Organized
4. Discuss the relationship between informatics and quality health care.
5. Identify methods to reduce data entry errors.

6. Demonstrate skills in using patient care technologies, information systems, and


communication devices that support safe nursing practice.
7. Apply safeguards and decision making support tools embedded in patient care
technologies to support a safe practice environment for both patients and health
care workers.
8. Understand the use of the CIS systems to document interventions related to
achieving nurse sensitive outcomes
9. Use standardized terminology in a care environment that reflects nursings unique
contribution to patient outcomes.
10. Evaluate data from all relevant sources, including technology, to inform the
delivery of care.
11. Recognize the role of information technology in improving patient care outcomes
and creating a safe care environment.
12. Uphold ethical standards related to data security, regulatory requirements,
confidentiality, and clients right to privacy.
13. Apply patient-care technologies as appropriate to address the needs of a diverse
patient population.
14. Advocate for the use of new patient care technologies for safe, quality care.
15. Reflect on ones own beliefs and values as they relate to professional practice.

Handout 1
Reflective Journaling

Guidelines for Reflective Journaling


1. Journaling is a tool that enables you to practice reflective learning and document your
understanding and learning through reflection. It is based on your experience that you
lived during your clinical experience.
2.

Remember, this is a reflection not a summary of the day events.

3. The journal is due Monday following your clinical experience. It should be turned in to
your instructor along with your clinical preparation from the previous week by 2359.

4. Please remember to maintain confidentiality of your patient. In writing about your


clinical experiences avoid using patient names or other information that may identify the
patient.

5. Chose a journal entry that is specific to your experience in clinical each week.