Posts Tagged ‘Healthcare Informatics Computer Charting’

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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Standardized Language in Healthcare

November 18, 2011

As the electronic health record (EHR) becomes increasingly utilized across the nation, a standardized language will need to be implemented and followed. This will improve more accurate billing, informed patient management, increased precision of documentation, and improve knowledge. Functioning without standards would be chaotic, out of control, and confusing to all individuals. Standardization proves to enhance any process. With the strategic organizational initiatives of many physician offices, clinics, medical centers, and hospitals to implement an automated electronic environment for documenting a patient’s health history, which then automate other processes, the need increases for the uniformity of a language. The downside of the uncontrolled terminology of medicine has been accentuated by the computer age, because without standard vocabulary the ability to acquire knowledge about healing professions through information technology is limited. Many clinical applications available today have restricted utility because they cannot understand each other. It seems with the urgency of healthcare facilities implementing EMRs, the development of a standard language is critical and needs to be on a fast track to develop solutions. Healthcare information system developers are not waiting for the standards bodies, in existence today, to make these determinations. These developers know that precise medical words are needed to analyze the information from automated medical records, which will improve quality and service in healthcare. Rather than use any existing clinical vocabulary standard, they are creating their own dictionaries or vocabulary sets. Although this represents a slight improvement over un-encoded or free text documentation, each vendor working in isolation, are creating a terminology which cannot be read or understood by other systems. This makes the potential of data exchange and comparing impossible. It is imperative that healthcare organizations, vendors, and government agencies work collaboratively to implement measures to effectively localize, update, and disseminate healthcare terminologies, mappings, and other terminology-related content currently issued by national and international standards bodies. A standardized language in healthcare is something of a monumental task, but one that needs dedicated professionals in establishing these standards. Although some standard languages exist, developed by various standards organizations, the need is paramount of unifying a standardized language. Controlled medical terminology is essential to maximize the true benefits of implementing a fully operational EMR. Additionally, if all physicians, nurses, patients, hospitals, clinics, payers, and government agencies would commit to the same healthcare language, the one who unquestionably benefits from this is the patient who can be any one of us.

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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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Nursing And The Electronic Invasion

November 15, 2010

I started my medical career as a Care Attendant, then a Licensed Practical Nurse, and finally a Registered Nurse. Over this time I have worked in two different states and seen many changes in the continuing evolution of the nursing profession.

The most recent changes have been primarily within the way we record our care. Over the past few years electronic charting has overtaken more and more aspects of our daily routines, not only do we record each patients vital signs within the electronic record, we record whatever they eat and drink, each use of the ladies and gentleman’s room, and most stressful for nurses, the exact times we medicate. We are given an hour, half our prior and half hour after the scheduled time of a medication to administer it. That doesn’t sound hard to do, but when staffing is short a nurse or a nurse assistant, more is expected to be done by each nurse on the floor. It is not always possible to adhere to this tight timeline, and all the time in the back of your mind you know that each day a printout is generated and sent to each nurse manager showing who was late with their medications, and each floor is sent a monthly record that is hung in the medication room showing each floor within the hospital and the percentage of times medications are administered on time, and when they are late.

We find that our computers on wheels are never more than a fingertip away, and the information that we put within the electronic record is growing with each passing day. It is an electronic strangle hold that has the floor nurse’s attention rather than the patient having the attention.


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