Patient Tracer

The district nursing team were now to be responsible for the wound care of an ulcer on the sole of her right foot on her impending discharge. She had previously attended the practice nurse and a podiatry service based within her local clinic. Due to a change in circumstances, she was now clearly housebound for the near future due to mobility issues. Prior to an arranged visit, the patient had called the nurse to advise her that she was pyrexial and was experiencing a pain in her right foot that was different from her normal neuropathic pain, which was often problematic. She was also finding it difficult to mobilise and was disinclined for diet but was taking oral fluids.

§ inappropriate treatment of people with infection and lack of information in the person’s personal care plan

Wound management is one of the cornerstones for nursing care however, effective wound care extends far beyond the application of the wound itself. Nurses may be required to assess, plan, implement, and evaluate wound care; therefore, order to fill these roles it’s critical to have an understanding of the several different areas of wound care such as, integumentary system, classification of wounds, wound procedures, and documentation. Knowledge in each of these areas will allow nurses to make well informed decisions about wound care, and as a result play an active part in wound healing.

For example, a hospital-wide policy can be made making it mandatory for all critical results to be documented and reported within the hour. Attestations can be put in place for all hospital staff to sign, holding them responsible if policies are not followed. Another suggestion would be to have all critical results reported to two sources, for example the patient’s nurse and charge nurse, to increase the likelihood of rapid documentation. The point of the corrective actions is to ensure that each staff member knows what they are responsible for. For example, laboratory staff knows to document the critical values and alert the appropriate nurse or charge nurse, the nurse or charge nurse knows to document the critical lab values or test result and to alert the ordering physician, the ordering physician knows to discuss a treatment plan with the patient and to document appropriately in the chart, etc. The point is, every staff member has a role to play in assisting the hospital in becoming one hundred percent compliant. This corrective action plan holds each staff member accountable. Those who do not comply can easily be tracked and disciplined by their supervisor.

In the article, "Improving Patient Safety by Standardizing Handoff Communications" (Danis, 2007), the purpose of the study was to implement a standardized approach to handoff communication and to improve compliance in using a handoff communication form. The study was based on the lack of standardized communication as the root cause of issues surrounding how patients receive care and safety and addressed the JACHO 2006 National Patient Safety Goals requiring a standardized approach in handoff communications. The study found that implementing a handoff communication form increased communications about patients between staff of each department. It concluded that staffs were more aware of communication gaps and the difficulties in communicating in the complex health care environment. This study is important for bringing more awareness and solutions to the problem of interdepartmental communications to ensure that patients will continue to

An interview with an Assistant Professor at Duke University Health System in the Department of Medicine, Maestro Care Provider Champion and Clinical Content Architect. This physician works to incorporate clinical decision support tools into the electronic health record at Duke Health System. He manages the best practice advisory committee that may provide a way to deploy alerts to clinicians at the point of care. Alerts with order sets and recommended actions are created and updated to notify providers of current patient care guidelines or patient safety concerns.

This style of documentation standardizes the communication between the health care team, providing information and a sequence in which both parties know what to expect. The format allows data to be recorded in for basic categories which include Situation, Background, Assessment, and

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 benefit of standardized handoff reporting. Research shows the implementation of any standardized reporting format will improve communication between health care providers by reducing the risk of transferring inaccurate and incomplete patient information (Barry, 2014). In a study by Guilbeault et al. (2015), both verbal and non-verbal handoffs have been shown to reduce communication errors. While there is little information regarding an electronic handoff, it is expected to reduce the loss of information (Guilbeault, Momtahan, & Hudson, 2015). According to Braun (2012), allowing the electronic medical record to gather the information from multiple sources will reduce the time the nurse will spend gathering information and standardize the process (Braun, 2012). Despite the need for a standardized tool, a common format has yet to be accepted (Matney, Maddox, & Staggers, 2014).

Sherman Red is an 80-year-old male who was diagnosed with diabetes six months ago and is now admitted to the local hospital for a diabetic ulcer to his right great toe. The toe is infected and the patient is diagnosed with possible sepsis. The scenario depicts a presentation of sepsis in the elderly. This shows how wound healing and care of a diabetic patient can be difficult if not followed closely. The complication that can result from a diabetic ulcer can be devastating. It is always important that a patient is in full compliance with the treatment to prevent other health problems. The infection of the wound could have been avoided if treatment was taken seriously. The nurse must conduct a head to toe assessment of the

The risk factors that were identified by the nurse were the patient complicated medical history, her need for pain medication frequently, being newly transferred from the surgical floor and the confusion it may cause on who will be attending to her care. The nurse also identifies that being on the unit will be an adjustment, therefore she wanted to address safety issues

According to a Nightingale Community Hospital document, Mrs. Jane Doe, a 67 year old female, was admitted on 10/15/2012 for a laparoscopic hysterectomy. The hysterectomy was converted to an open procedure due to excessive bleeding approximately five weeks prior to hospitalization. Due to complications from the surgery, Mrs. Doe was readmitted for a possible post-operative infection. Five days ago, Mrs. Doe underwent surgery to treat an abscess formed from her previous surgery and for the insertion of a central line for long-term antibiotics (Tracer Summary, n.d.).

It was so good to see you last week. I have a CNO at All Children’s Hospital in St. Petersburg FL is looking for a client who has Cerner that a Children’s Hospital. She has a meeting in a few weeks with all CNO’s of Children Hospital and would like to meet with the two to talk about how they are using Cerner specifically the patient tracking portals boards. Let me know if you have any questions.

The result are The average harm rate for all hospitals was 60 per 1000 patient-days ranging from 34 to 84. The percentage of harmed patients was 25 and ranged from 18 to 33. Overall, 96% of harms were temporary. Infections, pressure ulcers procedure-related and gastrointestinal problems were common. Teams reported differences in training and review procedures such as the role of the secondary reviewer.

Accreditation requirements must be interwoven in natural flow within the context of the assessment and become more meaningful components to the assessment: