Neuro And Stroke Flowsheet: A Case Study

The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare.

Electronic Health Record (EHR) compliance is expected to achieve better clinical outcomes, improved population health outcomes, increased transparency and efficiency, empowerment of individuals, and more robust data for research on health systems (Health IT). The determination of this paper aims to evaluate the flow of information as it travels with patients as they enter the emergency room, up to and including a skilled nursing facility stay. Over the last decade an emphasis has been placed on transitioning from paper based documentation to electronic based computerized systems. The centers for Medicaid and Medicare place such high emphasis on this transition that monetary incentive including higher reimbursement rates

Health information technology is a familiar entity for most working nurses in the year of 2017. Many nurses, have lived through the transition from paper charting to online charting. This transition has not always been a progression of ease. Change is never easy. The process of paper charting with pen and paper and the use of paper medication administration records have been the routine process for many years. With the new onset of the electronic health record (EHR) many processes have become easier, safer, and more efficient while some tasks have become more complicated, confusing, and more time consuming. The goal of this paper is to describe the electronic health record system, expand on the essence

There’s no denying that EHR has advanced the quality of healthcare by improving the way information is accessed and exchanged. But despite these advancements, errors, which were simply not tolerated in paper records, are numerous in EHRs. Because of this, electronic documentation tools have been developed in an effort to increase the quality of clinical documentation, enhance communication between healthcare providers, and improve delivery of care.

Led by our chairs Samantha Sangabi and Julia Roh, our Power to End Stroke initiative has worked to break the barrier that lies between the community and the signs of stroke. With the help of the B.E.F.A.S.T method we have been able to reach out to the community and provide patients with the tools to detect and take preventative measures against stroke.

The role of an NI is categorized as a non-clinical advanced nurse. The use of core competencies is an integral part of delivering standardized, measurable, quality healthcare in this day and age. Informatics is a relatively new addition to the APN, and nursing education but an integral part of delivering quality healthcare to patients. In 2010, the Institute of Medicine (IOM) mandated that nurses be key players in transforming and developing the infrastructure that is needed for efficient health information technology (HIT), thus, improving the quality of health care. Presently, informatics is a requirement for all APN 's. In prior decades, informatics was in the embryonic stages of development, but in 1992, the ANA recognised it as a speciality thursting NI to the forefront of nursing education and integerating informatics into the the very core of nursing cirriculum.

The electronic health record has affected nursing in multiple ways. The EHR helps nurses provide fast and effective care by saving them time, and time

According to McGonigle and Mastiran (2015), EMRs on the surface suggest a simple automation of clinical documentation, in fact their implications are broad, ranging from the ways in which care is delivered, to the types of interactions nurses have with patients in conjunction with

Something to question is new electronic health records helping staff take care of patients or is it a burden. Nursing documentation is always necessary because it provides a reflection of what nurses do for their patients. Documentation helps ensures a flow with patient’s treatment team (Linton & Moon). When documentation is not done correctly or efficiently due to the new technologies it can place the patient at increased risk and added cost to the hospital. Many nurses feel too much time is spent on electronic documentation and not the patient. Nurses know that failure to document is hard to defend in court (Morales, 2014). Having standardized documentation in place can dramatically ensure that patients are getting taken care of, and not have to worry about missing or forgotten documentation and potentially finding health trends in the documentations (“The importance”, 2015). New documentation requirements are effecting nurses in a good way to make sure their care that they provide is being reflected on and noticed.

Nursing information systems (NIS) are “computer systems that manage clinical data from a variety of healthcare environments and are readily accessible to improve patient care (Biohealthmatics.com, 2006). The Electronic Health Record (EHR) is an electronic version of a patient’s medical history. This record is kept current by the provider and includes administrative information, clinical data, demographic info, progress notes, medications, vitals, past medical history, immunizations, lab data and laboratory reports (CMS.gov, 2012).

Electronic Nursing documentation increased health care quality for the patient. This can be seen because electronic documentation is done at each interaction that takes place within the patient’s room. This is known as point of care documentation (Duffy,Kharasch, Hongyan, 2010). Another benefit to documenting at the bedside is nurses have to physical see the patient in order to complete documentation, therefore increase

Slide 10: Within nursing practice, assessment, documentation, and communication are the most frequent activities, consuming 18.1%, 9.9%, and 11.8% of nurses ' time, but with EHR nurses have more time to analyze and deliver patient care. The selection of bedside or central station desktop EHRs will influence documentation time for the two main user groups, physicians and nurses (Vondrak, 2012).

This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the

If nurses spend too much time charting because of a deficiency in basic computer skills, these goals will not be reached. Assuming nursing staffs will receive the necessary training for electronic charting at the clinical site decreases the opportunity for the nursing profession to determine how nursing staffs will be trained to chart important nursing documentation. Nursing documentation is a foundation of nursing practice and helps determine if standards of care have been followed, possible areas of nursing research, and guidance for ways to decrease errors. The purpose of EMR training by clinical nurses is to ensure the objectives of the guiding questions were clear and measurable. Nurses’ ability to use an EMR effectively by demonstrating critical knowledge and skills that are essential to patient safety, decreased facility expenditures for training and decreased healthcare

As technology has and continues to advance so will the expansion of nursing informatics. Data from (19th annual 2008 himss leadership survey, 2008) hold this statement true showing a steady increase in the implementation of technologies. As computers became smaller, it became easier and efficient for hospitals and physicians office to implement their use. (sutton, 2007)The first computers were large, expensive, and inefficient. Now, computers are compact, inexpensive, and efficient. The smaller technology allows for portability of information. PDA’s are small enough to fit in your pocket. With these small devices, you can look up a patients medication, drug interactions, side effects, and just about anything, you could think of to