Posts Tagged ‘Health Care Informatics Resources Electronic Medical Record’

Foundations of an EHR

July 21, 2011

Identifying current processes, paper and electronic forms, (clinical decision support tools), and workflow processes is the foundation to building an effective EHR. When an organization manages its forms, paper or electronic, it manages its processes. Many forms are necessary for collecting and documenting patient information. Unfortunately, most organizations do not see the value of managing these documents. Whether for electronic or paper, forms management includes the design, creation, revision, and obsolescence of these decision support tools. Maintaining proper version control is essential to meet the current standards of documentation dictated by regulatory agencies and the organization itself. Standardizing forms used throughout the healthcare facility plays a large role in helping the clinical staff to know what data to collect and document which forms are available, and where to access them. This facilitates the delivery of proper patient care. Additionally, standardization saves costs not only in the production of the form, but also in the use of the form. Forms management does have an effect on patient safety and the quality of care. Proper forms management can greatly assist the development of an EHR. Understanding existing forms and processes is necessary for developing accurate electronic processes in the EHR. Before an EHR is implemented a disaster recovery plan must be defined. This plan must identify the paper forms required for use. These paper forms must continue to meet the requirements of creation, revision, version control, and obsolescence to meet the ongoing needs of the current documentation processes. It is necessary to have correct, backup paper data collection tools for clinical and business operations to continue. Often a forms analysis, which documents the current state, is a first step in migrating to an EHR. This is extremely valuable for an organization to know its current used forms, volume, costs, workflow, and production information. This enables the organization to make future decisions based on this information. If a bad process is not identified before automating it, one now has a very expensive bad process. Assessing the current forms management environment can significantly decrease this risk and increase the effectiveness of the EHR and guarantee its successful implementation.

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Importance of Skin Assessment in Elderly and Child Abuse, comment

May 17, 2011

This is one area where healthcare informatics can be of great help. Instead of nurses trying to remember what to assess and what to write down, the health electronic record will indicate what assessment needs to be done and documented. If the nursing and hospital administration wants skin assessment done, they can include it in the program. And they can set the computer program to indicate to the nurse when this assessment should be done. Thus, the nurse does not have to guess in most circumstances.

Another part of the medical electronic record is the use of cameras. Some camera systems are able to insert an image of the skin assessment directly into the electronic chart. This is a huge time saver for of all nurses. No more writing essays on what was seen on the patients skin.

Original Post
October 18, 2010
Importance of Skin Assessment in Elderly and Child Abuse, comment
Skin assessment is a more valuable tool than we give it credit or time for. There are so many clues to a long list of health issues; from the varience in color, turgor, texture, temperature and thickness, to hair distribution, and condition of the nails. All of these variances from norm could be linked to some health issue. Issues like nutritional deficiency, allergy, local or systemic disease; such as melanoma or systemic lupus erythematosus; or they could be signs or the ‘remnants’ of abuse.

Unfortunately, I don’t think the nurse on the floor routinely gives skin assessment the time or attention needed to pick up on these clues. The most opportune time to find these signs would be on admission, during the initial assessment. What I see on the floor, is short staffing more often than not, trying to care for more patients than can be fully cared for during their shift, and bed shortages, requiring ’quick’ turnover. I am also afraid that the gains in my staffing numbers over the past year are in jeopardy with the reforms and cuts in reimbursement that I think are coming. Thorough assessments are an essential part of health care, of preventative medicine, and all of our professional practices; so I truly hope there will be the time and ability going forward to complete this valuable task.

Original Post

May 26, 2009

Title: Importance of Skin Assessment in Elderly and Child Abuse

In studying skin assessment, one cannot help feeling overwhelmed. Without a desire to pursue dermatology, the unlimited amount of skin lesions, pustules, macules and papules can lead one to skim over information out of the pure necessity for mental sanity. The mind can only hold so many pictures at once. However, I do see the need to ensure the memorization and ability to recognize and diagnose normal skin variations. In reading articles and working with children and the elderly, one unfortunately sees the reality firsthand of physical abuse and neglect. This can often be recognized by assessing the skin. Breakdown, malnutrition, physical abuse, bruises, injuries at different stages of healing can all be noted by a thorogh assessment of the skin. As follow up care and the big picture should always be a part of our thought process in nursing assessment, the ability to note whether a skin assessment finding is simply normal or abnormal is vital to our practice.

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When Will Technology Catch Up

December 9, 2010

The age of technology has made great strides in the medical profession, improving the care of patients and in many ways making bedside nursing more efficient.  I began my nursing career in the mid 1970’s, everything was done on paper, the lab would come and draw blood at 6 o’clock in the morning to tell us what a person’s blood glucose was for insulin coverage prior to the bedside glucose monitors we now have.  The younger nurses that I work with love to hear about the “old days when” from myself and other nurses who have been around for more than a decade.

As we go through our daily work week we have cat scan, x-ray, lab draw results continuously flowing through our computers, usually available within an hour of a patient being tested, allowing for further testing and treatment decisions that use to take up to 24 hours or longer for doctors to accomplish, are now accomplished during a single shift.

From Monday to Friday information flows smoothly most of the time, but then it is the weekend and it seems that time reverses and we are in another era.  This past weekend was my weekend rotation, I recall one patient in particular that was hoping to go home, his discharge was going to be determined by the results of  an echocardiogram that was done early Saturday morning.  His cardiologist came in at 1 o’clock, no report was available within the computer or when cardiac testing was called.  Sunday came and went, Monday morning the man was discharged.

This scenario was seen more frequently prior to the technology now available to us,  however it needs to be available seven days a week to give the best care possible and save money, the weekends need to catch up technologically with the Monday through Friday work week.

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The Bright Side Of The Electronic Medical Record

November 18, 2010

Clients and their families having satisfaction with their hospital experience has taken it’s place at the forefront of patient care. Although this is not a new concept, it is having more emphasis placed upon it than ever before.

With the emergence of the electronic medical record there have also emerged new ways to bring satisfaction to our clients. Nurses have much more information at their fingertips than ever before, we rarely have to leave a patient’s bedside to answer their questions. If they have a question concerning one of their medications, the nurse can click the icon on their computer and find the answer the patient seeks, and can just as easily print out this information for the client to refer to. A client that is on a fluid restriction who wants to know how many more glasses of water they are able to have can have their answer instantly with a click on the input and output tab, where an up to the minute tally is readily available.

In many instances the nurse also benefits, if a client asks for pain medication, there is now a colored line that shows up next to the medication as to what time the medication can be given, there is no more searching for the last dose and counting the hours between doses.

The newer versions of the electronic medical record have a client’s lab values and allergies, not only a click away, but automatically have a pop up box that warns the doctor or nurse who orders or is about to administer a medication, such as potassium, that there is a contraindication with the daily lab results or the clients allergies.

As a profession, nurses go through many transitions in the daily care of their clients. Some of these transitions may be difficult to adjust to, others have flaws and need to be adjusted to better serve the nurse and client. Our attitude can make all the difference, looking at the bright side with a positive attitude can make our work experience a more positive one. One thing is for certain the electronic age is not going to go away, it is here to stay.


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