QI Project Reflective Essay

Amatayakul, M. K. (2009, January 01). Electronic Health Records: A practical Guide for Professionals and Organizations. VitalSource Bookshelf(4). Chicago, Illinois, USA: AHIMA Press. Retrieved August 2012, from <http://online.vitalsource.com/books

My clinical site utilizes an electronic medical record. This system is integrated with the nearby hospital system. Information is placed directly into the patients’ electronic medical record (EMR). Details related to the history and physical are entered as information is obtained during each visit. Behavior and psychosocial details get recorded in a standardized template such as a SOAP note.

Along with the new technologies applying in healthcare, the documentation processes and storages also change from paper charts to computer-based electronic health records (EHR). Many healthcare organizations currently maintain patients’ health records in both formats of paper and electronic. The combination is known as hybrid health record system, which is used to assist in different methods that patients’ information is collected. Hybrid health records (HHR) contain specific patients’ health information. HHRs are stored manually and electronically in multiple places. Current patients’ health records usually contain both digital documents and handwritten notes. Patients’ data are electronically stored, such as laboratory, radiology tests,

Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports (Ehlke & Morone, 2013). The incentives from both of this articles will result in the delivery of quality care to many individuals in

It is vital that you begin by evaluating your unit’s readiness using the tools offered by the Agency for Healthcare Research and Quality (AHRQs) TeamSTEPPS initiative (Team Strategies and Tools to Enhance Performance and Patient Safety) (AHRQ, 2011).

We live in a digital age where everything from photos to important documents is saved or stored online. This includes the use of electronic medical records. The electronic medical record (EMR) is useful in assisting physicians to have a complete and thorough health history of the patient. The EMR serves as a continuity of care from one hospital to another within the same organization (Hsieh, 2014). Consulting physicians also have quick access to recent diagnostic imaging, progress notes, and lab results. EMRs can help manage patients with chronic disease states, aid in data collection for use in research, and prevent adverse drug events (Hsieh, 2014).

Many health care facilities are already starting to use an electronic health record in some of their departments. An electronic health record is a system that allows health care employees to input patient information into a computer system and saves that information into a database for the facility. The information that is being stored directly into the computer system is patients’ personal information (name, date of birth, address, emergency contact information, insurance information, and primary care physician and/or admitting physician), medical history, allergies, current medications, nurses and doctors’ notes, and other information that may pertain to the reason for the visit. Radiology and lab results are also saved into the electronic health record. Even though some health care facilities use a computer system to save some information, there may also be paper work that is also being used. This paper work is scanned into the facilities database so that it can also be saved and viewed if necessary.

It is hard to take a snapshot of the current technology used in healthcare as tomorrow a new innovative idea is right around the corner. A major change that has occurred over time comes from the use of electronic health records (EHR). Electronic health records usage has been on the rise for several years. It has been used by physicians, ambulatory staff, and HMOs. Since data can be easily altered the copies that must be certified for any medical provider to reference. There is a criterion for the composition of this data due to the exchanging of patient information within an interoperable medical

The scenario selected for this evaluation project focuses on the electronic health record. The scenario involves patient documentation, clinical decision support, and performing nursing notes. The project involves evaluation and implementation of EHR. The electronic health record and clinical decision support are not only relevant to my current organization but also are particular interest of mine. The electronic health record has helped to reduce the amount of paper which was a nightmare to maintain with the number of new patients being admitted daily. The electronic health record has also reduced the amount of missed documentation and errors. Any clinician can testify to the wasted time and poor communication among providers that sometimes results because antiquated paper records still predominate in our offices and on the hospital wards (Shortliffe, E. H., Tang, P. C., & Deimer, D. E., 1991). The clinical decision support system has been a great assistance to clinicians. Nurses, health visitors and midwives, as the largest group of healthcare professionals, record and generate most of the information used to maintain and improve patient care (Levy, S., & Heyes, B., 2012). Clinical support systems (CDSS) integrate information (ideally from high-quality research studies) with the

Meaningful use is the adoption and use of certified health record tech, entry/capture of data (vitals, orders), movement of data (transitions of care), report data (to larger clinical systems) (SuccessEHS, 2012). Issues

We will divide the team in different groups designated to different section of protocol like patients’ inclusion and exclusion criteria, safety, analysis. Each group will study their section and shared information with the whole team.

One of the most transcending advances that technology has allotted the healthcare field is the use of Electronic Health Records (EHR). Simply stated, EHRs are a contemporary approach to storing patient’s information by exchanging paper for technology (Colorado Technical University, 2017; HealthIT, 2017). Among the information that found in E H R’s include Administrative and billing data; Patient demographics; Progress notes; Vital signs; Medical histories; Diagnoses Medications; Immunization dates; Allergies; Radiology images; and Lab and test result (HealthIT, 2017).

Electronic documentation provides clarity in orders for tests and medications as well as the ability to identify and properly bill for services rendered. The change to electronic documentation from paper charting is not an easy task, but one that is needed to remain current with the needs of healthcare, and will lead to improved medical records. This paper will discuss the background of electronic medical records (EMR) use at Eglin Airforce Base (AFB) using dimensions defined by the Institute of Medicine (IOM), review a theoretical underpinning of change, illustrate an improvement tool, describe a model for quality improvement (QI), examine the resources required for change, and propose evaluation methods of quality measures.

The medical or healthcare record has multiple purposes. First, it is repository of documentation of the actions taken in patient management, the documentation of a patient’s progress, and therefore a mean’s to augment one’s memory and knowledge as well as to provide meaningful medical information to other practitioners should the patient transfer to a new provider or should the original provider be unavailable for some reason. The health electronic health record system that is currently in use at my facility is Cerner. Cerner retained the top spot for community hospitals of 101-250 beds for the same time period; it also came out the best for hospital systems. I will discuss the role of this system as it relates to memory, computation decision support and collaboration. Although there are some minor issues I have noticed throughout the years I find navigation through this system is secure and easy to use.

* The Gantt chart: Still accepted as an important management tool today, it provides a graphic schedule for the planning and controlling of work, and recording progress towards stages of a project. The chart has a modern variation, Program Evaluation and Review Technique (PERT).