Practicum Project: Creating a Women and Infants Clinical Summary Screen 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. Project Objectives The initiation phase of a project is not complete without a clearly defined goal and realistic, measurable objectives that describe the business benefits which are expected to be delivered upon completion of a project (Laureate Educatio... ... middle of paper ... ...tained from my preceptor, instructor, and from colleague feedback on my final project course deliverables. This summative evaluation will serve as lessons learned to enhance my performance in future information technology projects. Summary This practicum project experience project plan is the initial step in addressing an identified deficiency in the new CPOE/clinical documentation system implemented last year at the medical center at which I am employed. Using the standardized tools of project management, I have presented the project objectives, the global project methodology, and the formative and summative evaluation criteria. To further describe this project plan, a graphical timeline is shown in figure 1. A narrative explanation of the timeline is included in the appendix. Finally, this project plan is supported by scholarly and peer-reviewed literature.
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.
This systems limits patient involvement creates a delay in patient and nurse visualization. Prior to implementation of bedside shift reporting an evidenced based practice educational sessions will be provided and mandatory for nursing staff to attend (Trossman, 2009, p. 7). Utilizing unit managers and facility educators education stations will be set up in each participating unit. A standardized script for each nurse to utilize during the bedside shift report will be implemented to aid in prioritization, organization and timeliness of report decreasing the amount of information the nurse needs to scribe and allowing the nurse more time to visualize the patient, environment and equipment (Evans 2012, p. 283-284). Verbal and written bedside shift reporting is crucial for patient safety. “Ineffective communication is the most frequently cited cause for sentinel events in the United States and in Australian hospitals 50% of adverse events occur as a result of communication failures between health care professionals.” Utilizing written report information creates accountability and minimizes the loss in important information during the bedside shift report process (Street, 2011 p. 133). To minimize the barriers associated with the change of shift reporting process unit managers need to create a positive environment and reinforce the benefits for the procedural change (Tobiano, et al.,
The current medical review process at a proprietary MAC (henceforth referred to as “Well Health”); will be reviewed for the course project. At Well Health, incoming service requests from healthcare providers are received by fax and made available to the nurse reviewers in electronic format using a computerized application. Once received by the reviewer, the nurse must access numerous web sites and programs to complete the medical necessity review process. Each of these applications is much like the standard electronic health records (EHR) utilized in many ...
Projects are widely used by many organizations and government institutions in the course of conducting their business. One of the reasons for this is because they have been proven to be effective in initiating change and translating strategic programs into daily activities. However, it has been established that most projects fail to deliver on time, budget, and customer specifications. In most cases, this failure is caused by over-optimism by the project management team. This over-optimism commonly referred to as optimism bias can simply be defined as overestimating the projects benefits and conversely underestimating its cost and duration time. Research have portrayed that this is often caused by failure to properly identify, understand, and manage effectively the risk associated with the project therefore putting its success at jeopardy(Mott McDonald, 2002). Fortunately, this biasness can be detected and minimized during the project gateway process.
A literature review was conducted using CINAHL and PubMed to locate relevant articles published from 2010-2017. Keywords were education, bedside, shift report, bedside nursing, and communication were all searched in varied combinations. The search resulted in 20 suitable articles for review. Welsh, Flanagan, & Ebright (2010) examined factors that influenced exchanging shift report in their 2010 study. They analyzed nurses’ evaluations of different report styles. The authors discovered that bedside report improves professional communication. The article suggests that bedside reporting helps assure that nurses are no longer side-tracked by socialization or interjections of personal opinions like they can be during other types of handoffs.
Jugdev, K. (2012). Learning from Lessons Learned: Project Management Research Program. American Journal of Economics and Business Administration , 4(1), 13-22.
Retrieved from: Ashford University Library Boaden, R., & Joyce, P. (2006). Developing the electronic health record: What about patient safety? Health Services Management Research, 19 (2), 94-104. Retrieved from http://search.proquest.com/docview/236465771?accountid=32521.
Clinical documentation improvement (CDI) is the process of reviewing the clinical documents by specialists to response to concerns regarding coding issues, quality and care management of patients’ services. According to Oach and Watter, hospitals invest in CDI programs to guarantee the contents of electronic health records (EHR) indicate actual conditions of their patients. CDI assists in reducing chances of unclear and incomplete documents, which may lead to losing hospitals’ revenues. CDI promotes the accuracy of documentations, which results in correctly coded and billed to insurances to decrease rejection rates, increase payments compliance, and improve quality of report for researches of public health data and diseases’ trends. CDI is
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
Putting together my clinical notebook required lots of thought and planning before beginning to put it together. I wanted my notebook organized in a way that I could easily and quickly find what I was looking for. I separated the information the way that the modules are separated in nutrition assessment. I began my binder with the nutrition care process model and finished with Nutrition Focused Physical Assessment module. It was challenging but I am happy that I went with this organization because I can easily find quickly the information I need in it. I went through each module and the power point presentations to ensure I had everything that would help me in the future. I included eNCPT terminology, DRIs, lab values, and many useful equations.
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...
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).
Four activities in the nursing process that are defined within meaningful use and have been observed in clinical rotations include code status, such as allow natural death (AND), diagnostic labs, health history, and increased patient safety documentation. Documentation into the electronic health record (EHR) can be very challenging. These four activities or nursing processes are part of the stages within meaningful use criteria. Code status involves the patient and family in their health care. Involving the patient in their health care is part of stage one in meaningful use (HealthIT.gov, 2013). Diagnostic laboratory testing is also part of stage one by using information to track the patient’s condition (HealthIT.gov, 2013). The health history
When planning a new project, how the project will be managed is one of the most important factors. The importance of a managers will determine the success of the project. The success of the project will be determined by how well it is managed. Project management is referred to as the discipline that entails the processes of carefully planning, organizing, controlling, and motivating the organization resources so as to foster and facilitate the achievement of specific established and desired goals and meet the specific criteria of success required in the organization (Larson, 2014). Over the course of this paper I will be discussing and analyzing the importance of project management.
The authors of this article helped support their points on the importance of documentation by analyzing the different charting techniques, interviewing nurses within the field, as well as forming a number of focus group