Forms control is the organization and standardization of specific forms used to document occurrences of treatment and care in a medical setting. These specialized forms aid in reducing errors in addition to allowing all users access to the specific part of the medical record they need to do their job.
For example, when patients are discharged the discharge summary is integral to the continuum of care for patients when leaving any care facility. “Key components ….include: detailed information about follow-up and management plans, pending test results and mediation reconciliation” (Wimsett, Harper & Jones , 2014, p. 430). The problem is that “discharge summaries are often incomplete and lack information such as main diagnosis [and] discharge
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Recent research shows that “interventions used by the NP during the study are within a registered nurse’s scope of practice and can impact discharges by providing critical information for patient’s safe transition in care from hospital to “(Ruggiero, Smith, Copeland & Boxer, 2015, p. 167). This is important because it demonstrates how a concerted effort of staff and documentation (i.e. form control) helps to manage better patient care. Quality care doesn’t exist without the two together.
For example, when “a patient is admitted to [the] hospital; if their notes are not available a past discharge summary will provide useful information to the medical team who may have no prior knowledge of the patient, this is invaluable” (Pocklington, & Al-Dhahir, 2011, p. 41). This means the medical team has valuable intelligence that prevents duplication of services and next steps can be taken towards diagnostic testing to rule out what may be ailing the patient.
When the discharge summary forms are incomplete and are coupled with patients that may be incapacitated to the point that it is cumbersome to follow instructions; accuracy is crucial. Therefore, the organization and uniformity of the form and how information is presented is a detail that cannot be overlooked. Form control assures the details are
The adoption of clinical information systems is one way that healthcare organizations are making an effort to improve patient safety, provide a means to exemplify regulatory compliance, and facilitate exchange of patient information between care providers (Kirkley & Stein, 2004; Nadzam, 2009). To achieve this goal, Barnes-Jewish Hospital (BJH) recently implemented a new CPOE/clinical documentation system. One of the objectives of the new system was to give bedside clinicians a standardized electronic tool, known as the Clinical Summary, for bedside shift hand-off reporting. Soon after go-live, it was identified that the standard nursing Clinical Summary did not meet specialized the reporting needs of the nurses on the Women and Infants divisions. Consequently, an application enhancement request was submitted. The goal of this project is to synthesize the knowledge gained throughout this Masters Degree program to initiate, plan, and execute changes to the current clinical documentation system to provide a standardized Clinical Summary review screen to meet the specialized hand-off reporting needs of the nurses on the Women and Infants divisions at BJH. This paper includes project objectives, a supporting evidence-based literature review, project methodology, formative and summative evaluation criteria, and a graphical timeline with a narrative description for the Women and Infants Clinical Summary project.
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.
Nurses also refer to vital signs when assessing for deterioration but findings showed omissions were apparent in observation charts, lacking empirical evidence preferred by doctors to assess and advice further action. The review also highlighted ineffective communication between nursing and medical staff with problems experienced communicating complex information between different disciplines (NPSA
As a certified medical coder (CCA 11/2012), I have contributed to the HIMS department by helping code inpatient encounters from patients in the Residential Rehab Unit as well as outpatient encounters from the other clinics at this VA applying the official coding conventions outlined in the International Classification of Diseases 9th revision handbook as well as in the VHA’s Official Coding Guidelines, V11.0 dated August 10, 2011. Having coded many encounters over the past 3 years, I can easily determine the main condition after study that is chiefly responsible for a patient’s admission to the hospital. ICD-9-CM defines this as the primary diagnosis code and I find that it is most important to list this code first in your documentation
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
When a patient is unable to make care decisions for themselves, it is necessary to involve those closest to them, most often family members. Providing a supporting environment to family members is another way that the best interest of the patient can be maintained. Families and friends can make a huge difference in the life of the patient after discharge. Instructing families in a way that is easy to understand helps eliminate potential barriers to communication. Families should be aware of what things to look for, what would constitute an emergency, and how to safely handle
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
Healthcare professionals associated with medical billing and coding know the progress the technology has made so far. In the last few decades, medical billing and coding has switched from being a paper-based system to a computerized format. Under HIPAA laws, medical practitioners had to develop new software in order to send out electronic bills. With the advent of electronic medical records (EMR), with one touch of a button, doctors, Nurse Practitioners and PAs can gain access to all the care a patient has ever received from every healthcare facility the patients visited previously and can figure out possible illnesses. This enables statistical documentation of the population as a whole as well. EMR can also make the healthcare system more transparent and allow integration with reimbursement data. As the healthcare system changes, this will prevent unnecessary costs and make it easier to get the reimbursements needed to treat a patient.
Nurses have a considerable amount of responsibility in any facility. They are responsible for administering medicines and treatments to there patient’s. While caring for there patients, nurses will make observations on patient’s health and then record there findings. As well as consulting with doctors and other healthcare professionals to plan proper individual patient care. They teach their patients how to manage their illnesses and explain to both the patient and the patients family how to continue treatment when returning home (Bureau of Labor Statistics, 2014-15). They also record p...
The role of a Registered Nurse cannot be neglected in the provision of quality and safe care to patients and adopt procedures adequate for the condition of the patients because they work at the front line level; moreover, they have direct dealing with patients and integration of personal and professional skills is necessary. Therefore, there are certain attributes that are necessary to be present in a Registered Nurse for accurately performing various tasks. These include; Workload management, leadership qualities, interpersonal skills, control of practice, professional development, effective communication skills and organi zational loyalty (Daly & Carnwell 2003, pp. 158-167). These attributes hold significance in terms of obtaining positive outcome for not only the Registered Nurse but also the organization and the patient. Workload should be managed in such a way that the care process is not affected. Registered Nurse should have leadership qualities to help, motivate and inspire other nurses. Similarly, a Registered nurse should also enable and promote learning opportunities for other nurses. A Registered Nurse has responsibilities towards the subordinates, patients and most importantly to the organization. Effective communication skills can allow Registered nurses to establish a trusting relationship with patients identifying their problems and needs. The code of ethics and principles of practice must be followed and the practice of the nurse should be in the line of the organization’s working principles. The responsibility should be met as accountability factors must be considered significant in healthcare setting (Cornenwett, et al, 2007, pp.122-131; Bradshaw et al 2012, pp.13-14). ...
The nurse to patient ratio is unrealistic in many hospitals. In most cases it is almost impossible to give each patient the true amount of detailed care they really need. This is seen in most cases where there is one nurse assigned to 16 patients and each patient requires a different level of attention. Nurses are pressed for time, forcing them to cut corners, resulting in an increase in nosocomial infections and patient deaths. “The past decade has been a unsettled time for many US hospitals and practicing nu...
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
The ASF at my precepting healthcare facility used multiple forms of nursing documentation including both hardcopy and electronic methods. Oftentimes the hardcopy nursing notes would be discarded after the information was entered into the Computerized Patient Record System (CPRS). The task to develop an effective electronic nursing note that would eliminate the need for duplicate documentation on hardcopy forms and decrease the amount of time spent charting was initiated.
Dougherty, L. & Lister, s. (2006) ‘The Royal Marsden Hospital manual of Clinical Nursing Procedures: Communication 6th Edition Oxford: Blackwell Publishing Ltd
Electronic forms need special consideration, they need to be user friendly, meet standards such ASTM, and meet the needs of several user groups. These documentation challenges seem overwhelming and that is when an administrator calls on the hospital’s