Title
DATA MINING IN THE EHR: AN ACTIVITY FOR BEGINNING STUDENT NURSES
Author
Revised from QSEN Website
Author: Daniela Eichelberger, RN, MSN CPHQ
Title: Clinical Associate Professor
Institution: Columbia College of Nursing
Put X in box to correspond with
the SLO (s)
Patient Relationship
Centered Care
Informatics/Technology
x
Nursing Judgment/Evidence
Based care
x
Put X in box to correspond with
the Competency (s)
Communication Skills
Nursing Process
Learning Needs
Documentation
Informatics
Prioritization
Nursing Judgment
Student
Learning
Outcome(s)
Professional Identify and
behaviors
Professionalism
Ethical/Legal
Quality Improvement
Patient Care Concerns
Systems
Patient Complications
Safe Nursing
Communication
Safety
Teamwork and
Collaboration
Knowledge/Practice/Ethical
Comportment
K
P
E
x
x
x
x
Conflict Recognition
Managing Care of the
Individual Patient
Managing Care of the
Individual Patient
Assign/Monitor
Where should this assignment be used:
Classroom
Clinical Setting
Independent Study
Online/Web Based
Skills Lab
Simulation
x
Revised from Linda Caputi © (What type of assignment is this?)
Patient Care Assignment
Non Patient Care Assignments
Patient Care
Thinking Focused
Patient Focused
Systems Focused
The assignments are related to
Assignments encourages
The student focuses on
Assignments help the
the student while providing
critical thinking and clinical
specific aspects of
student understand the
patient care in the clinical
reasoning and teaches
patient care such as
clinical world, the nurse’s
setting.
students to think like a
safety, falls, diabetes,
work therein, and the effect
Example: Concept mapping care
nurse.
other diseases, etc.
of the system on the nurse
for one or multiple patients.
and the patient.
Example: How the system
completes medication
administration from order to
delivery to patient.
x
x
1
2
Assignment: DATA MINING IN THE EHR: AN ACTIVITY FOR BEGINNING STUDENT NURSES
Competencies measured in this assignment:
INFORMATICS - DOCUMENTATION / CONFIDENTIALITY COMPETENCY:
Identify (K), demonstrate (P), and appreciate (E) the use of information technology to accurately document patient care
while consistently safeguarding confidential health information.
NURSING JUDGMENT/EVIDENCE BASED CARE-NURSING JUDGMENT COMPETENCY:
Identify (K), use (P), and appreciate (E) evidence based care when conducting a focused assessment, choosing nursing
interventions within a plan of care, monitoring, and reporting changes in the individualized patient's condition across the
lifespan.
Name: _____________________________________________Date: __________________________
INFORMATICS - DOCUMENTATION / CONFIDENTIALITY COMPETENCY:
1.
Locate the following information in the patient’s electronic health record
DO NOT PRINT any of the information from the EHR! Transcribe it below.
 Trended temperature over the past five days, or length of admission if shorter.
 Trended pulse over the past five days, or length of admission if shorter.
 Trended blood pressure over the past five days, or length of admission if shorter.
 Trended pain level over the past five days, or length of admission if shorter.
Date
Temp
Pulse
BP
Pain level
2. Identify the patient’s primary
admission diagnosis
Identify any relevant co-morbidities
(maximum 3)
3.
1.
2.
3.
Find the lab values that would be
important for this patient. (maximum
3)
Why are these lab values important to
for this patient?
Date
Lab test 1
Result
Lab test 2
3
Result
Lab test 3
Result
NURSING JUDGMENT/EVIDENCE BASED CARENURSING JUDGMENT COMPETENCY:
Determine if there is anything significant
about the data that you found. Explain your
answer:
4.
What do you see as the relationship
between the trended data and the
patient’s admission diagnosis?
5.
How did the trended data affect the
decisions you made about the patient
care you provided.
4
Rubric for Grading EHR assignment
Criteria
Satisfactory (__points each)
Needs Improvement (__ points each)
Trended
Data
Correctly documented the
trended information for the past 5
days.
Documented the trended
information but was not complete
and accurate. Needs occasional cues
and supports.
Unable to document the
trended information without
multiple supports and cues.
Dx
Correctly lists the admission
diagnosis and the co-morbidities
that were relevant to the
admission diagnosis.
Lists the admission diagnosis but
some of the co-morbidities listed are
not relevant to the admission
diagnosis.
Lists the admission diagnosis
but does not list any comorbidities.
Lab
Identifies labs results that are
important to the patient’s
diagnosis, identifies the value of
having the lab results and the
significance of the findings.
Identifies labs results that are
important to the patient’s diagnosis,
identifies the value of having the lab
results and the significance of the
findings but needs multiple cues and
supports.
Identifies lab results for the
patient but the results do not
relate to the diagnosis. Unable
to identify the value of having
the lab results and the
significance of the findings.
Focused
assessment
Able to identify a focused
assessment and the relationship
between trended data and
diagnosis.
Needs supporting cues to identify a
focused assessment and the
relationship between the trended
data and diagnosis.
Unable to identify a focused
assessment between the data
and diagnosis.
Pt. Care
Able to identify how the trended
data affected care given to the
patient.
Needed supporting cues to identify
how the trended data affected care
given to the patient.
Unable to identify how the data
affected care given to the
patient.
Points
Total
Points:
5
Unsatisfactory (__points each)
6