Clinical Decision Support ( Cds ) Strategies Essay

Clinical documentation Improvement (CDI) is the program or the training that is design to provide the good link between coders and health care providers that increase the accuracy and completeness of patient health care documentation. According to American Health Information Management Association (AHIMA) tool kit CDI is the program especially design for health care field for initiate concurrent and, as appropriate, retrospective review of patient health records for accurate, incomplete, or nonspecific provider documentation (Scharffenberger and Kuehn 2011). Most of the time patient health record review occur in inpatient location but it there is any confusion then the review can go through electronic health records too. CDI play a vital role solving complex case between coder and health care provider that result in easy and smooth operation of reimbursement process in health care organization for the service they provide to patient.

Clinical judgment is the clinical reasoning, which includes clinical decision-making, critical thinking, and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence- based guidelines (AACN, n.d.). In the case of F.S., he was on isolation precautions due to his infection. The results from the cultures had yet to return, therefore the infection was not identified at that current moment. The registered nurse that was assigned to F.S. went into the room several times without wearing proper protective personal equipment. This nurse stated that if she wasn’t touching the site, she was not at risk. This was a bad clinical judgment. Unfortunately, this was not the first time this student nurse witnessed the lack of use of the personal protective equipment. What most nurses don’t seem to understand is that the risk of infection is not only towards the patient but towards the nurse as well as everyone the nurse encounters. Contact precautions were researched and found to be associated with activities likely to reduce transmission of resistant pathogens, such as fewer visits and better hand hygiene at the exit while exposing patients on contact precautions to less healthcare worker contact, less visitor contact, and potentially other unintended outcomes (Morgan et al, 2013). Although it can be depressive for the patient to become isolated due to an infection, this

Standing (2011), defines clinical decision-making as a complex process that involves observation, gathering information, critical thinking, evaluating evidence, applying necessary knowledge, reflection and problem-solving skills. Every day nurses make important clinical decisions and these decisions have important implications for patient outcomes and deserve serious consideration. Therefore, it is important for nurses to have a better insight of the decision-making process, be able to deliver holistic care and meet essential and complex physical and mental health needs of the patient.

UHN in Toronto is a major community care network that reaches out to and provides care to the masses. However in order to provide this kind of care they must have a very powerful decision support system. UHN utilizes an advanced CPR to support computerized physician order entry (CPOE). (Wu, Perters, & Morgan, 2002) A CPR system is a computer-based patient record system. A CPR system must provide a comprehensive clinical decision support it must include both a patient focus and a population focus. The physical computer system that is installed on the computers at UHN is called Patient 1® which is a clinical information system developed by Atlanta Based Per-Se

I believe that the clinical decision making process associated with the actions to be taken in Jack and Jacqueline’s care were quite similar between the Canadian and the Rwandan perspectives. This is because both perspectives took on a holistic view of Jack and Jacqueline’s situation and thereby worked to develop goals that would not only address Jack’s physical health, but also the emotional and mental health of Jack, Jacqueline, and even Charles. These holistic based goals included, but were not limited to the utilization of various community supports to foster Jack’s cognitive development as well as the formation and implementation of diverse coping strategies for Jacqueline and Charles to use during times of stress.

The value of CDI clinical documentation improvement (CDI) programs are important to any facility that recognizes the requirement of complete and accurate patient documentation. Documentation is very critical because it validates the care that was given. Furthermore, it shares important data to the caregiver and improve claims processing (Leventhal,2014). The three challenges are getting physicians to buy into the program, physicians are extremely busy so they are not connecting the dots on clinical documentation, and training the physicians to get them to understand they need to do better documenting (Leventhal,2014).

The SCHC addressed meaningful use by recording patient demographics, maintaining an active medication lists and incorporating clinical lab test results into the HER, as apart of their meaningful use objectives. For recording patient demographics, they maintained data for accurate billing and ensured that the practice workflow was adjusted to capture all of the necessary patient data. They addressed active medication lists by following the requirements for e-prescribing. Patients were able to review their active medication list during their visit. Changes to the medication list were reviewed with the nurse and adjusted within the EHR system by the doctor. They communicated information for the care coordination process by making test results efficient and safe to access. Physicians were able to make real time decisions when they receive the test results from LabCorp, Quest, and other health

One technique that has shown tremendous promise is clinical documentation improvement (CDI). CDI helps physicians and coders increase coding accuracy and properly depict the quality of care delivered. CDI aids in communication as well as identifies those areas of the documentation process that could use some improvement and greater specificity. With proper implementation, CDI offers both procedural and financial benefits.

Systems – this level includes “clinical decision support system (CDSS)”. This level is ranked the highest because evidence is acquired from point-of-care databases that are linked to electronic medical records of specific patients (2015).

On the other hand, many physicians do not know the importance of the program. In this case, there is an extensive amount of pressure on organizations for them to perform quality care, use correct coding, and get measured accurately through the MACRA. In addition, engaging physicians with their clinical documentation process may be an important factor though a difficult task in all healthcare organizations. Clinical documentation has become a critical part of every patient encounter. In terms of meaningful use, it must provide efficient, accurate, and timely services because it is what patients depend on. The clinical documentation improvement (CDI) program is intended to facilitate an accurate depiction of the clinical status of patients as it gets transferred into coding. At the same time, coded data has the responsibility to report physician’s clinical information, reimbursement, and tracking trends. Physicians must have the right education towards coding necessities, which is vital to correct reimbursement and quality reporting under MACRA’s quality payment program. Essentially, clinical documentation improvement (CDI) programs must be implemented into physician practices as it helps educate them on the general specifications that documentation and certain practices for the ICD-10

The connections between auditing, accurate diagnostic and practical coding with CDI programs is that the clinical documentation improvement (CDI) is that revising and monitoring offers oversight for the CDI program, understanding into physician documentation and collaboration, and objective assessment of the performance and efficiency of individual CDI staff members as measured against the facility’s policies and

Identify areas that require further intervention and refer these areas to Clinical Documentation Specialists (CDIS).

The CDS and Meaningful Use program measures objectives to improve patient performance, and requires eligible hospitals and staff members to implement five CDS interventions for the entire EHR reporting period. According to the Health Information and Management Society(HIMSS), the “Five Rights” concept provides providers with options that are appropriate for their practice. The Five Rights include right information, right people, right channels, right intervention, and right points in the workflow( HIMSS, 2016). I believe that the five rights will help providers decrease medical errors and develop a stepwise approach to preventing drug to drug reactions. Thus, this program will be welcomed in my healthcare settings because it teaches staff

The value of Clinical Decision Support Systems is having additional avenues monitoring patient’s data input. The Clinical Decision Support Systems are offering notifications of patient’s record data to specified department or medical personal.

Formulation of the research question guides the type of data collection for the study and states what the study will ‘hypothesise’ (Polit and Beck, 2010). The CASP tool acknowledges that clearly-focused research question will describe the population studied, the intervention given and the outcomes considered (SPH, 2006). The research question in the SR is clearly formulated. The population of patients studied were general and critically ill hospital patients, the intervention was a SR and outcome to be assessed was about the safety of the CPOE and clinical decision support systems or CDSS (CDSS is a computerised medication prescription system) based on hierarchy of outcome measures (kindly refer to table 2 of SR) within ICU settings. Likewise, in the NR, the population of patients studied were general and critically ill patients, the analysis was done via a NR and the purpose of the study was to assess the results of CPOE on clinical and surrogate outcomes in hospitalised patients in both general and critical care settings.