Vital Signs

Clinical practice guidelines are systematically developed recommendations, usually based on scientific evidence, that help clinicians and patients make decisions about care in specific situations. This post explains how trustworthy guidelines are developed, how evidence is rated, how guidelines are translated into order sets and clinical decision support, the challenges of keeping them current, and nursing roles.

An anesthesia information management system (AIMS) is a specialized electronic record that captures and displays patient data throughout the perioperative period, especially during anesthesia care. This post explains how AIMS integrate with monitors and the EHR, their benefits for safety, billing, and quality, challenges such as data artifacts and alerting, and roles for CRNAs and perioperative nurses.

Human-computer interaction (HCI) is the study and design of how people interact with computers, aiming to make technology effective, efficient, safe, and satisfying. This post explains HCI and human factors principles, how poor design contributes to errors in EHRs, user-centered design and usability testing methods, and why nurses’ input is essential to safer clinical technology.

A radiology information system (RIS) manages the business and workflow side of medical imaging, from orders and scheduling to tracking, reporting, and billing. This post explains how a RIS differs from PACS, how it exchanges data with the EHR and imaging equipment, common workflow problems, and what nurses need to know about imaging orders and results.

A chief nursing informatics officer (CNIO) is the executive who leads strategy and implementation of technology that supports nursing practice. This post explains what CNIOs do, how the role partners with the chief nursing officer, CIO, and CMIO, why it matters for documentation burden and patient safety, and how nurses can prepare for informatics leadership.

VistA is the health information system the Department of Veterans Affairs built and has used for decades to support care for veterans. This post explains what VistA includes, how it influenced EHR design and medication safety, why the VA is moving to a Federal EHR, and what large system transitions mean for nurses.

Look-alike/sound-alike (LASA) drugs have names, packaging, or labels similar enough to be confused, a well-known cause of medication errors. This post explains why LASA errors happen, how organizations maintain LASA lists, and how Tall Man lettering, EHR search design, barcode scanning, and nursing checks reduce mix-ups.

Standing orders are pre-approved orders or protocols that allow nurses and other team members to deliver specific care when defined criteria are met, without waiting for an individual order. This post explains how they work, what CMS requires of hospitals, how EHRs support them, and how nurses use them safely.

Precision medicine is an approach to prevention and treatment that accounts for individual differences in genes, environment, and lifestyle. This post explains the Precision Medicine Initiative and All of Us, pharmacogenomics and tumor profiling, what health IT must do to store and act on genetic data, and how nurses support precision care and patient education.

Arden Syntax is an HL7 standard language for writing clinical decision support rules, called medical logic modules, in a form computers can execute and institutions can share. This post explains how medical logic modules work, why sharing rules proved difficult, and how newer standards such as Clinical Quality Language and CDS Hooks continue the effort.

Quality improvement (QI) is a systematic, formal approach to analyzing performance and making changes that improve it. This post explains the Model for Improvement and PDSA cycles, related methods such as Lean and Six Sigma, what research says about how PDSA is applied, how health IT and data support QI, and why nurses lead so much improvement work.

A laboratory information system (LIS) manages the workflow of the clinical laboratory, from receiving orders and labeling specimens to interfacing with analyzers and reporting verified results. This post explains LIS functions, how results reach the EHR, the regulatory and standards context, and why specimen collection and labeling at the bedside are critical links in the chain.

Clinical informatics is the discipline that applies information science and technology to improve how clinicians deliver care. This post explains what the field covers, how it relates to nursing and health informatics, what clinical informaticists do day to day, the certification paths for physicians and nurses, and why the field matters to patient safety.

A plan of care is a documented plan, based on assessment, that identifies a patient’s needs, sets goals, describes the interventions to meet them, and tracks progress. This post explains the parts of a care plan, the CMS requirement for nursing care plans, how standardized terminologies support electronic care planning, and how to keep care plans meaningful.

Health literacy is the ability of people to find, understand, and use health information to make decisions, and the responsibility of organizations to make that possible. This post explains personal and organizational health literacy, what research shows about outcomes, and how teach-back, plain language, and thoughtful health IT design help patients understand their care.

The electronic medication administration record (eMAR) is the part of the EHR where nurses see which medications are due and document each dose given, held, or refused. This post explains how the eMAR connects to CPOE, pharmacy verification, and barcode scanning, what research shows about its safety benefits, and what nurses need from it during every medication pass.

An advance directive is a legal document in which a person states health care wishes or names a decision-maker in case they become unable to decide for themselves. This post explains the main types of advance directives, how they differ from POLST forms and code status orders, what federal rules require of hospitals, and how EHRs make those wishes findable.

A workflow is the sequence of tasks, events, and handoffs people follow to get work done. This post explains sequential and parallel workflows, how health IT teams map current and future states, why workarounds appear when technology does not fit the work, and how nurses help design workflows that are safe and efficient.

A medication error is any preventable event that could lead to inappropriate medication use or patient harm. This post explains how medication errors are defined and categorized, where they occur in the medication-use process, how health IT helps prevent them, and how nurses serve as the last line of defense.

A care transition happens every time a patient moves between providers or care settings, such as from hospital to home or from the emergency department to a nursing facility. This post explains why transitions are risky, what interventions have shown, how health IT supports safer transitions, and the central role nurses play.