Also, how anyone could be discharged and be received at another facility without a full exchange of medical history is incomprehensible, especially when it refers to basic information such as current medications, as in this case (hypertension and cholesterol) medication are the most relevant and critical to properly manage to improve outcomes. From both a micro and macro perspectives the case of the 78 year old Raymond was clear that quality of life was absent from both a personal and population level. It is apparent that these segments of the population are falling through the cracks of the system. From a medical Technology standpoint, the advancement of technology and the use of EMRs should have assisted by having Raymond's medical record and medications listed as well as his hypertension. The use of an Electronic Health Record, could have identified Raymond's problems, and what may have been occurring with him at the time of his emergency visit.…
PCC can also improve clinical documentation by how they're charting templates that intuitively prompts staff to review and chart all pertinent clinical information (). PCC has a database that functionally allows users to enter information in one part of the chart and direct that information to other sections for auto-documentation as clinically indicated, such as the Resident Assessment Instrument/Minimum Data Set. This will ensure that every member of the healthcare team is being provided the most up-to-date clinical…
The system that my workplace currently use is called Cerner Millennium. I would rate the efficiency, speed, and storage capability to be very high. When I first start working at my current place of employment, documentation was 50% paper and 50% electronic with physician’s orders being 100 % paper. Then comes the implementation of computerized physician order entry (CPOE) and all its added benefits. The clinician’s care process works as a seamless flow of information with an integrated system.…
Before the use of electronic health records, there were paper charts. These charts lined large shelves that often filled entire rooms depending on the size of the healthcare practice or hospital. The idea of the electronic health record has been around for several decades plus years (Gartee, 2011). However, it was not until more recent years that the use of the electronic health record has become more widely used within the healthcare industry. In 1991, the Institute of Medicine of the National Academies sponsored various studies and developed reports that ultimately paved the way for the electronic health records that we use today Gartee, 2011).…
"For everywhere we look, there is work to be done. The state of our economy calls for action: bold and swift. And we will act not only to create new jobs but to lay a new foundation for growth. We will build the roads and bridges, the electric grids and digital lines that feed our commerce and bind us together. We will restore science to its rightful place and wield technology's wonders to raise health care's quality and lower its costs” (President Barrack Obama, Inaugural Address, 2009).…
One of the many innovations in health care is Electronic Health Record. This new system is digital, and it replaces handwritten patient's records. EHRs contains "medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results" (HealthIT.gov, 2013). The information can be shared between health care organizations, and health care specialists can see full medical history of new patients. All medical date in one digital record allows doctors to understand patients' medical issues better and treat patients more…
Electronic Medication Administration Records Affect on Patient Safety In today’s society it is excepted to receive exemplary quality care when admitted to a healthcare facility. This means that the patient is to receive safe and effective care from the nurse and interdisciplinary health care team, with the goal of obtaining positive patient outcomes. These goals can be partially obtained with the use of the advancements in information technology. Information technology has the potential to increase patient safety, improve continuity of care, and change the way healthcare is delivered (Moreland, Gallagher, Bena, Morrison, & Albert, 2012).…
Research for Evidence-Based Nursing Practice Outline In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed in efforts to modernize and use health care technology in a meaningful way (Huryk, 2012). As a result, there has been a dramatic shift in the way nurses care for patients at the bedside. With the introduction of the electronic health record (EHR), bedside nurses have been challenged with adopting new technology and workflows.…
Patient continuity of care could be drastically affected if medical history or record are not accessible to physicians. With electronic medical records…
In summary, use of structured communication tools during interdisciplinary rounds has partially been shown to improve patient outcomes (Townsend-Gervis et al., 2014), but this use does not significantly impact patient satisfaction (Cornell et al., 2014; Townsend-Gervis et al., 2014). Staff situation awareness of patients was the only variable shown to improve with use of the structured tools during interdisciplinary rounds between both studies (Cornell et al., 2014; Townsend-Gervis et al.,…
He uses his phone to text other physicians and nurses especially when on call. Whenever he interacts with patients, he needs to be able to see prior information from electronic medical records. Plus, Dr. Morstead documents daily patient interactions in the electronic medical records. In addition, almost all information and tests in the hospital are obtained with some form of technological devices. These devices are more and more integrated with each other to self-populate documents and medical records.…
Strategic initiatives should be formulated using evidence-based practice [“EBP”] that enhances the opportunity to achieve optimal patient outcomes. Patients and families expect to receive quality care when seeking healthcare services. Dr. David Sackett and colleagues defined EBP as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996, para 2). Sustaining evidence-based change can be difficult when individual clinical expertise and practice…
The use of electronic health records would allow healthcare staff to track and manage patients across the system. The patient’s health information will be documented in an electronic medical record to ensure all team members and specialist have appropriate access to the patient’s medical record. Therefore, keeping electronic health records on patients help the medical staff recognize gaps in care and help give the patient the care they need, when they need it. This can greatly reduce the likelihood of emergency room…
Foundation of Knowledge model Discharge Summaries relate to Electronic Health Records Nursing informatics is a specialty involving knowledge and technology. According to McGonigle and Mastrian, The Foundation of Knowledge model is a “framework for examining the dynamic interrelationships among data, information, and knowledge used to meet the needs of health care delivery systems, organizations, patients and nurses” (2015). The Foundation of Knowledge model includes acquired knowledge, disseminated knowledge, processed knowledge and generated knowledge.…
1 MEDITECH provides a comprehensive and cohesive EHR designed to help your organization increase patient safety, modernize processes, and improve communication across departments and care teams. They reaction helps staff react more quickly to issues and changing conditions by automatically pushing information out to the appropriate personnel and displaying it in a meaningful form. Hospitals and other care facilities using MEDITECH benefit from products designed to meet the needs of clinicians and staff like physicians, nurses, pharmacists, and financial information between departments and care teams. Cerner can help with a combined suite of digital solutions proven to reorganize administration, reduce costs and improve patient’s safety. Cerner solutions allow doctors, nurses and other official users to share data rationally across an entire organization.…