Nursing informatics is the specialty that integrates nursing science with computer and information science to manage and communicate data, information, and knowledge in nursing practice. Its aim is safer care, better decisions, and more efficient work — technology is a means, not the goal.

Data → information → knowledge → wisdom (DIKW)

Key systems

Interoperability is the ability of different information systems to exchange data and use the data exchanged. It allows records to follow the client across a network of providers.

Standardized nursing terminologies (e.g., NANDA-I diagnoses, NIC interventions, NOC outcomes, ICNP, and reference terminologies such as SNOMED CT) name nursing phenomena consistently so data can be compared, aggregated for quality improvement and research, and shared electronically.

Principles of good documentation

• Accurate and factual — objective observations and measurements; quote the client's words
• Complete — assessments, interventions, client responses, teaching, notifications
• Timely (current) — document as soon as possible after care; never before care is given
• Concise and organized — logical order, approved abbreviations only
• Legible and permanent — on paper, black ink; in EHRs, your own login
• Confidential — access only records you need for your work
• Authenticated — every entry identifies the author (signature or electronic credential)

Objective vs subjective vs judgmental

• Correct: "Grimacing, holding abdomen, states 'my stomach hurts,' pain 7/10."
• Avoid: "Seems in a lot of pain" or "uncooperative" without describing behavior.

Documentation formats

Other tools

• Kardex — summary card or electronic view of current diagnosis, orders, medications, activity, precautions, allergies; used for planning and handoff (usually not part of the permanent record)
• Intake and output sheet — totals and balance of oral, IV, and tube intake versus urine, stool, emesis, drains
• Nursing care plan — assessment, nursing diagnoses, outcomes, interventions, evaluation

Corrections and special entries (consistent with Fundamentals)

• Paper: draw a single line through the error so it stays readable, write "error" or "mistaken entry," then date, time, and initial; never erase, use correction fluid, or obliterate
• Electronic: use the system's amendment function; the audit trail keeps the original
• Late entry: label "late entry" with the current date and time and the time the event occurred
• Never chart for another nurse or let another person chart under your login

Verbal and telephone orders: accept only when necessary (e.g., emergencies), write them down, read back to the prescriber for confirmation, and have them signed per policy. Critical results are also read back.

Handoff reporting: use a structured tool such as SBAR (Situation, Background, Assessment, Recommendation). When calling a physician about a deteriorating client, identify yourself, your unit, and the client, then proceed with SBAR.

Information security in electronic records

• Use your own username and a strong password; never share credentials
• Log out or lock the screen when leaving the workstation
• Access only the records of clients in your care (role-based access); audit trails record who viewed what
• Do not photograph records or clients on personal devices or post client information on social media
• Electronic systems improve security but do not guarantee confidentiality; breaches by insiders and hacking remain risks

Health information systems in the Philippines

• The Universal Health Care Act (RA 11223, Section 36) requires all health service providers and insurers to keep a health information system that includes electronic health records and an electronic prescription log, uploaded through interoperable systems consistent with DOH standards, while upholding privacy under the Data Privacy Act.
• Province-wide and city-wide health systems must have a primary care provider network with patient records accessible throughout the health system (Section 17).
• Public health nurses report program data through the DOH Field Health Services Information System (FHSIS).

Big data and analytics use large volumes of structured and unstructured data to find patterns (e.g., which interventions are linked to faster recovery), supporting evidence-based practice and quality improvement.

Staff nurse

• Document care accurately and promptly; use approved terms and abbreviations
• Use BCMA and CDSS as designed; respond to alerts thoughtfully rather than overriding by habit
• Protect privacy and security of information
• Report system problems (downtime, wrong defaults, unsafe screen designs) as safety issues

Nurse manager / informatics nurse

• Represent nursing needs when systems are selected or designed; involve end users
• Lead change management, training, and support during implementation
• Evaluate outcomes (errors, time spent documenting, user satisfaction)
• Coordinate with IT staff, who handle technical problems; the manager's role is clinical and managerial, not technical repair
• Maintain downtime procedures (paper backup) for system failures

• The client record is a legal document and the main evidence of care; in disputes, care that is not documented may be judged as not done.
• The Data Privacy Act of 2012 (RA 10173):
  • Health information is sensitive personal information
  • Processing must follow transparency, legitimate purpose, and proportionality
  • Processing of sensitive personal information is generally prohibited except in listed cases — including specific consent of the client, when needed to protect life and health when the client cannot consent, and medical treatment by a medical practitioner or institution with adequate protection
  • Data subjects have rights, including access to and correction of their information
  • Controllers must use organizational, physical, and technical security measures and promptly notify the National Privacy Commission and affected persons of qualifying breaches (within 72 hours of knowledge of the breach under NPC Circular 16-03)
  • Unauthorized processing of sensitive personal information carries criminal penalties
• The Code of Ethics for Registered Nurses (Board of Nursing Resolution No. 220, s. 2004) states that accurate documentation of actions and outcomes of care is the hallmark of nursing accountability.
• Ethically, confidentiality supports fidelity and respect for autonomy; releasing information requires a lawful basis or the client's consent.

Case 1 — Busy night shift. A nurse plans to finish all charting at the end of the shift from memory.

• Correct action: document as soon as possible after each significant assessment and intervention; if an entry must be delayed, mark it as a late entry.
• Why: delayed charting causes omissions and errors and weakens the record's reliability.

Case 2 — Shared login. A colleague asks to use your logged-in account to enter a quick note.

• Correct action: refuse; ask the colleague to log in with their own credentials.
• Why: entries must be authenticated by their author; sharing access breaches policy and data privacy rules.

Case 3 — Barcode mismatch. The scanner shows a wrong-patient alert when giving an antibiotic.

• Correct action: stop, re-verify two identifiers and the order, and resolve the mismatch before giving the drug.
• Why: BCMA prevents wrong-patient and wrong-drug errors only if alerts are respected.

• Documenting a medication before it is given.
• Erasing or covering errors instead of single-line correction or electronic amendment.
• Writing opinions and labels instead of observable facts.
• Believing electronic records are always secure; security needs continuous management.
• Confusing interoperability with simply having computers; systems must be able to exchange and use each other's data.
• Assuming the nurse manager solves technical IT problems; managers coordinate, IT fixes.
• Charting incident reports in the client's record (see Topic 27).

• DIKW: data (raw) → information (meaning) → knowledge (interpretation for action) → wisdom.
• CPOE reduces handwriting and abbreviation errors; BCMA confirms right client and drug at the bedside.
• Interoperability = exchange and use of data across different systems.
• Standardized terminologies (NANDA-I, NIC, NOC, ICNP, SNOMED CT) allow comparable, shareable data.
• Document objectively, promptly, completely, and never before care.
• Single-line correction with "error," date, time, initials; never erase; late entries labeled.
• SOAP(IE) belongs to problem-oriented records; DAR is focus charting.
• Kardex = quick summary for planning and handoff.
• RA 10173: health data are sensitive personal information; principles of transparency, legitimate purpose, proportionality.
• RA 11223 Section 36: EHRs and electronic prescription logs, interoperable, privacy-compliant.
• Use your own login, log out, and access only records needed for care.