Archive for January, 2012

Progress, Change, Future

January 22, 2012

The future of healthcare information systems and a career in healthcare informatics holds exciting opportunities for healthcare organizations. Many improvements will be made in current technologies available. Although the concept of the electronic medical record (EMR) has been around for quite some time, we are just starting to see some advances in the actual implementation of automating portions of the patient medical record. To get to a fully automated health record, where all aspects of the legal medical record communicate to all systems, seems like a daunting task and yet so exciting to be a part of during these times. A career as a healthcare informatics professional will continue to be a desired profession and will gain momentum in the value these professionals will bring to an organization. Identifying their roles and responsibilities will become unique to each organization’s needs. Because of the many abilities and knowledge of healthcare informatics professionals, one healthcare facility may utilize these professionals in a different way and environment than another facility. Perhaps if there is not a developed informatics department, these professionals may even have different reporting structures based on where the organization sees them contributing and fitting into the organizational chart for that particular facility. The healthcare informatics field of study will be fundamental to bridging the gap between Information Technology Departments, Administration, clinical staff, physicians, vendors, and end-users. These positions are knowledgeable in a vast amount of areas, such as: information literacy, human computer interaction, human factors, usability testing, project management, working as change agents, standardizing language, evidence-based healthcare, numerous types of computer software such as database systems and spreadsheets. One cannot argue the fact that these knowledgeable individuals have developed skills, which bring much value to an organization. If these positions are utilized, directed, and supported, they will be extremely beneficial within a healthcare facility. Implementing, supporting, and maintaining an EMR is progress for any organization. The power of progress is amazing and builds upon each generation’s knowledge. Suppose each new generation had to rediscover numerals or language or medicine. The world would see no progress. Each generation stands on the shoulders of the previous generation to reach higher. Therefore, change is the price we pay for progress, and the EMR will bring about change for healthcare organizations. Change itself is not progress; it is the price we pay for progress. We will see some of the most advanced technology and the quest for a fully developed electronic health record will begin to take hold. As generations replace older generations an environment of automation will be expected and accepted by healthcare consumers and healthcare providers.

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Head to Toe Examination and Documentation

January 11, 2012

Completing a thorough head to toe assessment is a skill that takes practice and a broad knowledge base. No body system stands alone. Completing a quality assessment of one system may lead to clues about issues or problems in another system. Although head to toe exam is recommended, it is important for clinicians to develop methods that work for them. Patients may present with acute symptoms or complaints that do not allow time for a comprehensive exam. It is vital for the nurse to be able to discern what level of assessment is required for each individual. A patient who is in obvious distress will require a much focused assessment and relatively quick intervention. The type of assessment can also be affected by the health care setting. Nurses working in an outpatient setting may have more time to complete a comprehensive exam and history. Nurses working in hospitals may have multiple patients with various problems that require focused assessments for the sake of efficiency. Some may have a modified head to toe examination technique. Documenting assessment findings have been greatly facilitated in the facility for which I am employed. Each patient room is equipped with a computer to allow for immediate entry of assessment findings. All units have at least five to six, computers- on-wheels (COW) that can be taken from patient to patient if needed. It is interesting to observe the level of competence exhibited by nurses. Novice nurses tend to take copious notes on each system while more experience nurses can gather much information about his or her patients during the general survey. As assessment skills develop, nurses can gather information with minimal effort.

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Is it Necessary to Document Your Efforts in Providing Culturally Competent Care?

January 5, 2012

Cultural competence has been a responsibility addressed in nursing programs since before I became a student and I have noticed a steadily increasing amount of focus placed on the topic throughout the years. As with all aspects of nursing, there will always be room for improvement in how we conduct our profession in a culturally sensitive manner. It seems to be a basic understanding that any nurse be acutely aware of his or her own cultural beliefs, practices and biases. I also notice universal agreement that health care professionals need to attempt to learn about all clients’ cultural attitudes towards healthcare and allow for specific integration of these attitudes when at all possible. As this is a responsibility of the health care professional, is documentation of the practice necessary as well? Cultural competence can be applied in all aspects of nursing care; so documenting the practice is very complicated. Much discussion will be needed to determine how it can be applied to daily documentation without taking excessive time from other nursing responsibilities. A basic need of clients is to have their healthcare options given to them in their first language to maximize the potential for full understanding. Hospitals have addressed this need in a variety of ways including written translation of informed consent and having native speaking interpreters present during any medical explanation before “informed consent” is given. The practice of providing culturally sensitive care is then “documented” by the presence of the signed translated copy of the consent or the presence of the interpreter’s signature on the English version of the consent. The cost to health care providers in both the areas of finance and time is great to accommodate these needs. Therefore, the value of our current practice should be continuously evaluated in order to assure we meet the needs of the client without excessive cost. Value is the key word in this sentence. In the case of the written translated consent form, I have seen consents get signed without being read and this has forced me to think about the various reasons this might occur. Could the client read the consent? Although the consent was in the language self-identified by the client, was the terminology not familiar to the client? Were the opinion and “desires” of the healthcare professional deemed sufficient and therefore explanation not required? The signed consent, however, is placed in the client’s chart and acts as documentation that the client was explained the procedure in a manner facilitating understanding. Healthcare facilities are also managing costs by trying to minimize the amount of paper used in documenting. I have seen consents presented to clients in the form of laptop computers with electronic writing devices. Does this technology intimidate the patient and further compromise their comfort during their healthcare experience? I am sure the answers to the questions posed above are as varied as are the cultures and people of those cultures seeking healthcare in this country. Is it really of value, then, to “document” all of our efforts in providing culturally competent care? Or rather, should we seek to create an environment in healthcare settings where continued education and discussion enhances the healthcare professional’s awareness of the need for culturally competent care? This in turn might increase our accountability to this responsibility without further straining the healthcare system with the financial and emotional stress of balancing the application of good care with the documentation of the process.

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