Blossom Creek Documentation Paper

The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk

The Medical Record Management System your office implements is only as good as the ease of

Two organizations migrating to a common health information system would need a system that meets current regulatory requirements, meets the needs of the combined organization and their practice environment. The implementation of a common health information system would require an interdisciplinary group of forward thinking innovators, and an interoperable electronic medical record system that includes standard nursing terminology.

“a paperless, digital and computerized system of maintaining patient data, designed to increase the efficiency and reduce documentation errors by streamlining the process.”(Santiago, n.d., para. 1)

Medical treatments require a great deal of paperwork. Before patients are allowed to go through treatments, a clinic must process their insurances, medical records, and surgery details. As a result, a lot of private information is gathered within the hospitals. With so much private information, it is essential for healthcare facilities to efficiently organize their paperwork. An unorganized recording system can prove disastrous to a hospital. Leaving patients’ paperwork publicly unattended and misplacing a file are both considered negligent. Misplacing patients’ information can potentially lead to information theft and invasion of privacy. An efficient way of storing information can be valuable in preventing HIPAA

According to Rosenbaum et al. (2015), healthcare documentation combined with clinical communication that is coded for hospitalized patients is an important part of medical care. The paper or electronic healthcare record is then submitted to third party payers that provide reimbursement for services based on the guidelines of the Centers for Medicare and Medicaid Services (CMS), Medicare Severity Diagnosis Related Group (MS-DRG), and inpatient prospective payment system (IPPS) (Rosenbaum et al., 2015). The

When external requests come from an acute care hospital or nursing home for the release of information (ROI) for a patient’s medical records, various procedures take place. The ROI clerk must be knowledgeable of all the federal and state regulations and any laws that are involved. Whether it is paper-based, hybrid, or electronic, the procedure is still the same. The patient must sign a consent form or letter of authorization and must be accompanied by the request form to have any documents released. Upon receiving this request, the ROI clerk enters the request in a database to log the request, then needs to ensure the forms are valid before the patient information is released. Once the patient has been verified, then, only the specific information

While these tools theoretically address well-known requirements for and common errors associated with clinical documentation, mismanagement can often create information integrity concerns. Health care systems must have processes in place to ensure all digital documentation used in care, research,

There are inherent risk and benefits of hospitals utilizing electronic medical records. Three problems that could occur involve workflow, registration and drug interactions. The aforementioned are problems that spill over into the other because they are interrelated. This is caused by inconsistency among “disparate systems,” communication between departments and errors involving medication (Gartee, 2011, p. 183).

Bar-coded medication administration (BCMA) systems are also commonly used by nurses to improve medication administration in inpatient settings. As an illustration, a study in 2007 showed that BCMA systems reduced medication administration errors by 54-87% in hospitals in the US. It has been reported that a large number of medication errors happens at care transition points, i.e., during admission, transfer and discharge of patients. Thus, medication reconciliation at all transition points could significantly improve medication safety. In fact, preliminary evidences suggest that application of electronic medication reconciliation systems are quite effective in reducing such errors. Additionally, electronic personal health record (EHR) systems can be used to reduce medication errors. These IT systems allow patients to access, coordinate their health information and make it available to their healthcare providers. IT systems are also used to reduce medication errors of omission. As an example, recent studies have demonstrated that smart electronic discharge systems utilized in some hospitals can alert physicians to prescribe important medications.

Accurate and comprehensible medical records documents are crucial for a positive outcome for the patient and health care providers. Health records sequentially convey significant details concerning patient’s health history and future care plans. These records are pertinent when initiating care in the acute and chronic setting for the patient. Medicare, Medicaid, and other personal health care providers necessitate rational documentation to guarantee that a procedure and/or examination is consistent with the individual’s health care coverage. The documentation also authorizes the place of health care treatment, eligible medical requirement and suitability of diagnosis and/or therapy, and that the services rendered were appropriately documented. Precise and reliable medical documentation should be recorded at the time of treatment or shortly after the intervention. Inappropriate documentation can result in erroneous and inappropriate imbursement for provided health care services.

(a) Patient’s not wanting to change from paper to electronic records, they want to stick with what they already know, (b)Patients and staff having negative feelings to the portable records without even trying them, (c) Communication issues may arise between staff and the mediator, (d) and staff may have difficulty with patient education because not all patients know how to work with electronics.

In defining the selection and acquisition framework for the healthcare information system under consideration, the creation of an Information technologies (IT) strategic plan is first needed. By definition, an IT strategic plan defines in very specific terms how a proposed IT system will align with and contribute to the strategic plans, objectives and goals of a healthcare organization (Davis, Adams, 2007). The process of selecting and acquiring the healthcare information system under development needs to take into account change management, process-based, systems-integration and lifetime cost of ownership considerations. In addition to these factors, a balanced scorecard of system performance and its contribution to each department in the organization also needs to be assessed (Chow, Ganulin, Haddad, Williamson, 1998). Healthcare system planning and evaluation has progressed beyond the basics of defining functional performance aspects of software towards the inclusion and encompassing of how roles in a healthcare enterprise can be made more efficient from their use (Spil, LeRouge, Trimmer, Wiggins, 2011). The process of selecting and acquiring the information system then must be designed to take into account stakeholder's needs while also delivering financially significant value to the enterprise over time (Davis, Adams, 2007). The intent of this analysis is to define how the

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.

“Information Systems follow a life cycle of conceptualisation to develop. The cycle allows refinement of definitions and plans in response to information uncovered during implementation, more detailed analysis or external changes in the environment. This cyclical process is consistent with the iterative approach to implementation the programme, which allows for testing and refinement through controlled, phased roll out”. (Messe and Cubitt, 2015)