Healthcare is constantly changing with the intention of improving patient care. The Institute of Medicine (IOM) issued a report introducing five core competencies for health professionals, in order to improve the Untied States healthcare system: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics (Institute of Medicine of the National Academies, 2003). IOM proposes that if all five core competencies are utilized by health professionals, quality patient care can be achieved. The facility in which this nurse work, is in need of improving their charting system. The facility currently utilizes two different software systems for charting, in addition to …show more content…
There are a number of ways in which patient care can be improved with a facility that utilizes multiple charting systems. The simplest way to provide effective quality care is to implement the EHR. A EHR is an electronic system consisting of a complete patient medical health history of past and current conditions (Keller, 2016; Menachemi & Collum, 2011). In addition, to the patient’s demographic, diagnoses, medications, treatment plans, allergies, laboratory data, immunizations, and test results. EHR decreases medical errors such as misinterpretation of clinical notes, doctors orders, not having access to paper chart that have yet to be filed or has been missed file (Keller, 2016). EHR also allows for quick and easy access to diagnostic test results and patient notes that are needed for patient care. EHR will significantly enhance patient care by reducing the amount of time it takes the healthcare team to retrieve the needed health information to deliver patient care. It will also dramatically reduce medical errors that are associated with the nursing staff manually entering doctors’ …show more content…
The biggest challenges with integrating a new software system includes the financial cost of acquiring the it and the training that goes with it. Another challenge would be the staff themselves, as many employees can be against change. Al-Abri (2007) reported changes to be a complex and challenging process. Implementing changes are more successful when staffs have a clear vision of why changes are being implemented and how it will impact them directly. For this process to happen, changes need to be communicated in a clear and precise manner to the staff. Moreover, change agents need to be readily available to answer questions and provide reassurance of a positive
For years now, the healthcare system in the United States have managed patient’s health records through paper charting, this has since changed for the better with the introduction of an electronic medical record (EMR) system. This type of system has helped healthcare providers, hospitals and other ambulatory institutions extract data from a patient’s chart to help expedite clinical diagnosis and providing necessary care. Although this form of technology shows great promise, studies have shown that this system is just a foundation to the next evolution of health technology. The transformation of EMR to electronic heath record system (EHR) is the ultimate goal of the federal government.
This technology assist the nurse in confirming patients identify by confirming the patients’ dose, time and form of medication (Helmons, Wargel, & Daniels, 2009). Having an EHR also comes with a program that allows the medical staff to scan medications so medication errors can be prevented. According to Helmons, Wargel, and Daniels (2009) they conducted an observational study in two medical –surgical units one in the medical intensive care (ICU) and one in the surgical ICU. The researchers watched 386 nurses within the two hospitals use bar code scanning before they administrated patients’ medications. The results of the research found a 58 % decrease in medication errors between the two hospitals because of the EHR containing a bar code assisted medication administration
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...
...f clinical information systems in health care quality improvement. The Health Care Manager. 25(3): 206-212.
In the clinical setting there are clinical and non-clinical advanced roles. A clinical advanced nursing role is one that involves direct patient care. An example of this is a nurse practitioner who provides treatment to patients and medical testing. A non-clinical advanced nursing role is one that does not provide direct care to the patients. Examples of this include nurse educators and nurse administrators who do not provide direct treatment to the patients. Both the clinical and non-clinical advanced roles have core competencies specific to their specialties.
Today health care systems are expected to meet set standards and core measures to earn everything from accreditation and recognition to payment. Reports need to filled to accomplish this, as well as what is being done to improve areas that may not be meeting standards. One way this is done is by utilizing dashboards. The purpose of this paper is to analyze the data from a dashboard and develop a nursing plan for improvement of a low scoring area.
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.
Know the importance of patient values, preferences and expressed needs as part of the clinical interview, implementation of the care plan, and evaluation of care.
To continue my career with the Port Authority and utilize my administrative skills to benefit mutual growth and success in the agency. My core competencies are creative thinking, organizational and planning, oral and written communication, attention to detail, initiative, decision-making, adaptability, and teamwork.
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
Healthcare is a continuous emerging industry across the world. With our ever changing life styles and the increased levels of pollution across the world more and more people are suffering from various health issues. Nursing is an extremely diverse profession and among the highest educated with several levels ranging from a licensed practical nurse (LPN) to a registered nurse (RN) on up to a Doctorate in Nursing. Diane Viens (2003) states that ‘The NP is a critical member of the workforce to assume the leadership roles within practice, education, research, health systems, and health policy’.
“There are two concepts in electronic patient records that are used interchangeably but are different-the electronic medical record (EMR/EHR) and the electronic health record. The National Alliance for Health Information Technology (NAHIT) defines the EHR as the electronic record of health-related information on an individual that is accumulated from one health system and is utilized by the health organization that is providing patient care while the EMR accumulates more patient medical information from many health organizations that have been involved in the patient care. The Institute of Medicine (IOM) has been urging the healthcare industry to adopt the electronic patient record but initially
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,
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...
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can