Patient Observation Report Sample

I would like to share the a procedure at my work where we spend about 15-30 mins every morning to conduct a 6S audit where we need to go through a checklist and make sure that critical things required for work are in place and ready to use.

13. Which of the following characteristics makes it EASIER to measure the quality of a service, relative to that of a product or facilitating good?

One of our branch goals for DBR 2017 deliveries is to maintain procedures inventory and perform annual audit. I wanted you to review procedures of the desk that you are working on. You are required to perform this task quarterly. Below are dates that our procedures are assigned to your names.

Other patient information you may find is documentation for any allergies the patient may have. Insurance information will be noted if the patient is covered were you will find the provider, the billing address, and the patient’s policy number. There will be many different forms in this system that are used to document things such as the patient’s family history, diagnostic results, immunization records, past and present medications taken and the effectiveness of them, and of course there will be doctors notes for any office visits and hospitalizations. In the doctors notes and hospitalization notes you will find documentation for medical conditions or diseases the patient may have had in the past or has presently. Last but certainly not least there will be the common release and authorization forms, there may be advanced directives or living wills on file if the patient has completed them and other relevant information that staff and medical facilities may need to provide quality care for the patient. (Whatis.com, 2008).

In order for the team members to be effective EHR users they must have basic computer knowledge. Before an electronic system goes “live” training is provided typically 4-6 weeks in advance to maximize user proficiency and patient care outcomes (McBride & Tietze, 2016). After the launch of an EHR system users are provided with ongoing support by super

The system was confusing at first, but once I started clicking around and exploring, it became easier to understand and locate the information I needed. I was able to find information like why the patient was there, vital signs, labs, allergies, past medical history, and medication schedule. After doing assessments I was able to document those findings and observations made during the assessments. For this task, I could improve by taking my time to chart and not chart findings vaguley. For my next clinical day, my goals for this task include taking my time while documenting, and to remember not to leave my patients information up on the screen if I walk

6. Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate

Conduct training and implementation of EHR system by installing the system and implementing training for staff on how to use the system.

This will be a double check off to insure safety. We will start a chart audit at projected start date July 1, 2012 and review in 90 days. The checklists will assure that all verifications and site identifications have been carried out.

21. Report any unusual or major changes in your patient’s health, cleanliness, physical care, actions and

The health center made sure the EHR was easy to implement and wanted it to emphasize quality measurement while creating business workflow to ensure quality input standards. After the implementation, the SCHC staff attended a mandatory 3-week training, organized & taught by the hospital staff. The training was job specific,

All staff directly or indirectly connected to the EHR will be educated in the safe and professional use of patient information. The first group of staff to be trained on the EHR will be “super users” (SU’s). The super users will be the clinicians provided with extensive training on the software program and its safety features. (Simmons 2013. Pg 53). These clinicians will be the mainstay in the building between the staff and the informatics department. Each department in the facility will have 3 super users, 2 full time employees and 1 part time employee to rotate and fill in the gaps ensuring there is never a day without a super user. These individuals will receive 6 months of training comprised of 3 days/week at 5 hrs/day. After this is completed, all staff will be educated including employees, medical staff, contractors, volunteers and students. These training events will be a time to ask for feedback on health information safety and HIPPA laws. The feedback received during training will be used to monitor risks to the facility. (MN DOH, 2014 pg 4). Also we will be “sending compliance reminder emails routinely” (MN DOH, 2014 pg

Requirements: Each individual is required to complete 1 hour per month of reviews. You can choose anytime during the month. Heather will send you a calendar where you can indicate the day/time you plan to complete your reviews. This is a 1 year assignment and will conclude on August 1, 2017.

Clinical documentation is vital to the success and care every clinical facility provides for their patients. It is a time-stamped process that includes all medical data performed by the hospital. It gives detailed analysis of procedures that were done, reasons why and past medical history. This gives the patient and hospital a detailed summary which helps improves the effectiveness

Mr Johan experiences symptoms of panic attack when he feels self-conscious in front of other people when performing certain tasks. He reported feeling faint and had black out of thoughts during those episodes, whereby he was not able to think of anything. Both his hands would tremble and become numb. He would also be sweating but experienced no symptoms of pounding heart or choking