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Overview of clinical documentation improvement
Poor documentation of patient care
Overview of clinical documentation improvement
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Using a system to access health information can have a positive effect on the quality and delivery of nursing care and patient outcomes. Health information systems can dramatically improve the ability of providers to diagnose diseases. When providers have reliable access to patient’s health information, they can see a clear picture which can help providers in diagnosing patient medical issues quicker. A health information system can reduce errors which can positively affect patient outcomes. The HIS can keep records of patient medications and allergies and will automatically alert clinicians when if there are any potential issues. The HIS is a crucial component in the delivery of nursing care. Documentation is an integral part of nursing
...benefits of this type of clinical decision support system include easy access to information and patient records, provision of timely support throughout the care process, reduced costs, enhanced efficiency, and reduced patient inconvenience. However the disadvantages include potential difficulties in interpreting information, difficulties in handling the huge amount of nursing literature, and probability of additional demands to care process.
Case 1 -- You work in a busy multi-specialty clinic with a high patient volume. The physicians enter the type of code that will yield the greatest reimbursement. You suspect the codes are not accurate.
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
The task of documentation is vital to nursing practice. Many times, however, this documentation is repeated in different areas of a patient’s chart. DiPietro et al. (2008) reported that 40% of the written documentation done by nurses was on personal paper at the patient’s bedside. This had to be copied into the formal patient record at a later time, resulting in double documentation. The reason nurses are forced to use this method of documentation instead of transcribing assessments directly into the chart is that this vital record of the patient’s information is often not readily available. Because several disciplines of the healthcare team require the chart throughout the day, there is no guarantee as to when the nurse may actually have access to it. Additionally, in almost all hospitals that utilize paper charting, the chart must travel with the patient when he or she leaves the floor for testing or procedures. This creates another roadblock to all members of the healthcare tea...
Learning Experience Journal Entry – Director of Health Information Management and the Supervisor of Medical Records Coder
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
Information Systems/Technology and patient care technology for the improvement and transformation of health care is an important part of the DNP. Technology has transformed every aspect of human life in positive ways. Technology brought efficiency and improved healthcare deliverance system. Healthcare technologies enabled practitioners to better understand disease process and how to implement best treatment plan. DNP programs across the country embrace information systems and technology in their nursing curriculum because, it prepares nursing students to be innovative and deliver best care (AACN, 2006). DNP graduates must have the ability to use technology to analyze and disseminate critical information to find solutions that
Health information management involves the practice of maintaining and taking care of health records in hospitals, health insurance companies and other health institutions, by the use of electronic means (McWay 176). Storage of medical information is carried out by health information management and HIT professionals using information systems that suit the needs of these institutions. This paper answers four major questions concerning health information systems.
Also, these studies question those who are effected; in this case, those who are most effected, is everyone. Doctors and nurses spend the most time working within these systems, but the information that is put into these systems effects every individual in America, because it is their information. Because nurses are often considered “both coordinators and providers of patient care” and they “attend to the whole patient,” their opinion is highly regarded (Otieno, Toyama, Asonuma, Kanai-Pak, & Naitoh, 2007, p. 210). It is clear that the use of these new systems is much debated, and many people have their own, individualized opinion. This information suggests that when there is a problem in the medical field, those who address it attempt to gather opinions from everyone who is involved before proceeding. It has been proven by multiple studies that this system of record keeping does in fact have potential to significantly improve patient health through efficiency, and it is because of this that the majority of hospitals have already completed, or begun the transfer from paperless to electronic (Otieno, Toyama, Asonuma, Kanai-Pak, & Naitoh,
Over the past decade, technological advances have paved the way for nurses to provide, quality, safe, standardized and individualized patient care (Saba & McCormick, 2015). The use of the Electronic Health Records (EHR) to manage patient data is quickly becoming widespread in the healthcare industry. The emerging use of the Electronic Health Record, is transforming how nurses care for patients. By creating and implementing an electronic, comprehensive, standardized method of recording patient data, nurses can facilitate and coordinate patient care with members of the multidisciplinary healthcare team. The use of the Electronic Health Record will promote positive
As humans when we are faced with any psychological or emotional problems, our initial thought is to turn to a therapist, doctor or any other health practitioners. Our initial thought when we are faced with problems regarding our health is to turn to a health professional because for ages that’s how it has been. When it comes to our health, health professionals nowadays do more harm than help. Many might disagree, but often patients are misdiagnosed with mental illnesses they do not have. Misdiagnosis occurs when a therapist or other health practitioners decide that a patient is suffering from a condition that he or she may not be suffering with. When misdiagnosed, patients are given unnecessary treatment, which could potentially
Technology is stated as the scientific method and material used to achieve a commercial or industrial objective. To go one step further, nursing technology is using a tool to advance nursing practice. “The Institute of medicine identified that technology as a viable method of enhancing patient care delivery and improving staff productivity” Sensmeier, Horowitz (2003 page). Because inadequate nursing staff causes shortcuts to be taken, there are mistakes made that could have possibly been prevented. Errors by nursing staff were variously reported as being responsible for between 44,000 and 98,000 hospital deaths per year. Sensmeier, Horowitz (2003). Technology can have a large impact on nursing. In the past 5 to 10 years, computerized patient records have increased less than 10%. This number shows us that we are still not embracing technology to its full potential. Today in most hospital systems computerized electronic charting is being used. Many hospitals have many different systems for...
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
William Goossen’s theory can be applied in nursing practice to develop nursing informatics skills and knowledge, as well as develop technological system competencies among nurses to collect, process, retrieve and communicate pertinent information across health care organizations (Goossen, 2000). This theory is highly applicable in addressing matters related to electronic health records, which are currently characterized with issues of privacy and confidentiality in relation to storage, retrieval and reproduction of patient health information. The model also provides broad applicability in guiding research at any clinical setting and contributes to the discipline of nursing by simplifying and enhancing documentation and storage of patient’s health information and by allowing better utilization of nursing resources (Elkind, 2009).
Documentation is a form of communication that provides information about the patient and confirms that care was provided to that patient. Some reasons why nurses document is for communication and continuity of care of the patient and by that it means clear, complete and accurate documentation in a health record ensures that all those involved in a client’s care, including the client, have access to information upon which to plan and evaluate their interventions. Next, quality improvement/assurance and risk management through chart audits and performance reviews documentation is used to evaluate quality of services and appropriateness of care. Additional reason is it establishes professional accountability because documenting that is showing a valuable method of demonstrating that nursing knowledge, judgment and skills have been applied within a nurse-client relationship in accordance with the Standards of Practice for Registered Nurses. Another purpose is for legal reasons the client’s record is a legal document and can be used as evidence in a court of law or in a professional conduct proceeding. Courts may use the health record to reconstruct events, establish time and dates, and refresh one’s memory and to substantiate and/or resolve conflicts in testimony. Although you may never be named as a defendant in legal case, you may be called to testify at a discovery or