...Identification of the educational need and rationale: The implementation of electronic documentation for medical records, medications, and nursing flow sheets has replaced the existing paper documentation and is currently the educational need with the highest priority for the Emergency Department at the University of Massachusetts Memorial Medical Center. In a continuous care operation, it is critical to document each patient’s condition and history of care, to ensure the patient receives the best available care. The medical record documents the care of the patient and can immediately be accessed, updated, and passed among the interdisciplinary team of caregivers. The Emergency Department is the initial passageway to the hospital for most patients. Electronic documentation is a patient’s health information including medications, allergies, past and present illnesses, and family history can be gathered upon their initial presentation and up-to-the minute revisions can be made by the healthcare team throughout their hospital stay. The Electronic Medical Record/Charting can be designed to hold collaborative information from all providers that are involved in the patients’ care. With each subsequent visit thereafter, the patient’s demographic, insurance, and health history database will automatically pre-fill the electronic template alleviating nurses of time restraints associated with paper documentation. This allows for quick updates to the patient’s profile if necessary. Patients...
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...Electronic Documentation Nursing is a fast changing profession that has been vital to providing care in the medical setting. Throughout the past several years one of the most recognizable changes in the medical field is the transformation from paper charting to electronic forms of documentation. This has led to a decrease in the amount of paper charting by allowing nurses to use check boxes, cell formatting, and computer databases to keep patients records more accessible and organized. As new forms of technology become available we find that there are often flaws that need to be assessed and corrected to properly implement an optimal computing system. The clinical integration paper examines the positive and negative aspects of electronic documentation in the nursing field as it pertains to time management, patient safety and its efficacy. It was found that nurses spend the largest proportion of their time at the nurses station documenting and coordinating patient’s care with twenty five to fifty percent, which results in less time spent on patient care (Blair & Smith, 2012). This is alarming knowing that approximately a quarter to half of a nurse’s shift is done sitting in front of a computer documenting the day’s events. At Central Baptist Hospital I believe that more than half a day could be taken up by computer charting. From what I have experienced, a nurse may begin their shift with anywhere between four to six patients. These patients require a general...
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...Learning Needs Assessment Paper Vicky Doss, RN, BSN NUR 588-Developing and Evaluating Educational Programs May 7, 2012 Monie Nuckles, MSN, RN, PhD(c) Learning Needs Assessment Continuing education is of the utmost importance to any organization regardless of type. In order for nurses to remain current and updated within their profession there must be access and motivation to education. Nurses must strive to increase their knowledge base to provide the best and most effective care based on the most recent evidence available. Nurses must have the necessary skills to remain competent in a quickly evolving health care system. “The provision of adequate, suitable, flexible, and quality continuing education that takes into account the needs of the individual nurse can lead to improvements in the quality of nursing care” (Claflin, 2005, p. 263). It is essential to provide the appropriate type of education, depending on the learner’s style in order for nurses to stay informed and adjust to the changes in the healthcare system and provide adequate care for the patients he/she treat. One of the most influential factors in the need for continuing education is the need to make sure that patients are treated in a cost and time effective manner to prevent readmissions and prolonged stays. In order for any of this to be effective, first the learning needs of the staff need to be assessed to discover what is important to them. Performing this needs assessment...
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...organization to assess and evaluate the organization’s compliance with selected standards and the organization’s systems of providing care and services. Surveyors retrace the specific care processes that an individual experienced by observing and talking to staff in areas that the individual received care. As surveyors follow the course of a patient’s treatment, they assess the health care organization’s compliance with Joint Commission standards. They conduct this compliance assessment as they review the organization’s systems for delivering safe, quality health care. ("Tracer Facts," 2012, para. 1) For this assignment I have reviewed the tracer patient summary information and there are several outstanding patient care issues. Some of these are related to documentation, such as history and physical exam not completed timely, lack of documentation pertinent to functional assessment, plan of care documentation outdated, and the lack of pain assessment documentation following medication administration. I have elected to address the patient care issue of documentation since many elements of the patient tracer revealed documentation to be a concern. The old motto goes, “if it is not documented, it was not done”, therefore, appropriate documentation is critical not only for successful patient care, but also for the delivery of safe and quality health care. Documentation is always a high risk item and often there will be deficiencies noted on audits and surveys due to the large number...
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...Effective Communication Introduction In a long-term care (LTC) nursing facility, the primary types of communication are documentation and verbal. The physicians and all of the nursing staff have to document every aspect of each patient’s care. Effective documentation provides a legal record of care and how the patient responds to the type of care which they received. By documenting, the physicians and nurses are giving written communication to those who provide follow up care. When the nursing staff begins their shift, the nurse gives a report of their previous shift’s activities. For example; the night nurse gives the day nurse reports on each patient. Without these verbal reports the nurses, Certified Nursing Assistants (CNAs) would need to read each individual patient’s chart to see what happened on the previous shift, this would take away valuable time from the patient and could lead to negative patient care. By using documentation this type of communication provides a legal record of care for each patient. The LTC facility uses several documents to monitor each resident’s care and the outcomes from the care. Each resident also has a personal medical record (PMR) these record contain the resident’s medical, family, social history, assessments, dietary needs, treatment plans, orders, prescriptions, progress notes, and lab results. With this chart the LTC has a complete and accurate look into each individual resident and their medical history and progression of care. ...
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...The Importance and Implications of Evidence Based Practice-Research Patricia Davis Immaculata University The Importance and Implications of Evidence Based Practice-Research Evidence based practice is a way of providing health care that is guided by incorporating current knowledge and clinical expertise. This research and resource information corrects clinical problems, application of quality interventions, and evaluates the outcomes for further improvements in the future. Evidence based practice is an approach that improves the impact of nursing, psychology and social work. It gives research the cause and effect that gives validity to the information. The purpose of evidence based practice is ensuring that patients receive the best quality care and keep nurses, nursing care, and knowledge up to date. The American Nurses Association (ANA) recognizes the importance of evidence based practice (EBP), and that it incorporates the registered nurse to integrate, participate in the formulation, and contribute to the knowledge of research to improve healthcare outcomes (ANA, 2010). Evidence based research results in favorable patient outcomes across various geographic locations. The impetus for evidence-based practice comes from decisions of efficacy, and healthcare facility pressures for cost containment. Evidence practice stresses changes in the education of students, more practice-relevant research, and closer working relationships between clinicians and researchers...
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...Abstract Nursing Informatics as we have learned over the course of this class is defined as computer science mixed with nursing and information science. This paper will present my view of the advantages of nursing informatics and how it has enhanced the quality environment in which we work as nurse's work and has changed how we care for our patients. The most basic advantage is that it improves communication between all disciplinarians of the health care industry and I will make my statement of how I believe this communication can be of advantage to all of the healthcare industry. The Advantages of Nursing Informatics and Quality Improvement The world of nursing is changing on a daily basis and we, as nurses need to adapt and change in order to provide our patients with the ultimate care they deserve. The hospital environment as a whole has changed over the years and is now a business and the patients are our customers. The advances and advantages of nursing informatics in my opinion will deliver safe and superior quality care for our customers in the health care industry. In 2008 a landmark report from the Robert Wood Johnson Foundation, "Nursing Time and Motion Study" it was revealed through a 36 hospital study, how important the workflow optimization is in the nursing field. I found this to be a very eye opening report as it revealed that less than 20% of a nurses' time is spent on patient care activities and only 7 % of the nurse's...
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...Advanced Information Management and the Application of Technology Western Governors University Adam Culbertson A. New Information Management System Implementation of a computer system to replace paper documentation would require the involvement of an interdisciplinary team. This team would be comprised of several members, each with a specific job. The first member selected would be a Clinical Nurse Informaticist. This team member would be charged with giving valuable input on the software needed for nurses to properly care for and chart on their patients. With the knowledge of nursing practice and informatics, this team member would very valuable in bringing the two together in the most efficient way possible. The next team member would also be from the IT department. A Director of Clinical Informatics would be chosen for this project. The Director of Clinical Informatics play a vital role in the project because of the knowledge of current hospital technology, upgrades that may be needed, software that is available, and regulations for patient privacy. A Chief Nursing Information team member would in charge of researching what each department needs in a software system. With each unit being different in charting needs and the flow of the unit, this team member would be very important and work closely with the Clinical Nurse Informaticist. These two team members would work closely with nursing staff to ensure everyone becomes competent with the system once it is in...
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...Changing Paper Documentation to Electronic in Healthcare Name Institution Date Introduction Changing from paper documentation to electronic documentation is just like switching from analog to digital television. Rigidity in institutions may prevail but at the end all the institutions conform to one documentation method the electronic documentation. An electronic document is any media content other than computer system files or programs used in either soft copy form or paper as a print out (Yu, 2006). With technological advancement, the use of written documents has reduced because it has become easier to distribute and display documents in screens (AWARE, 2005). The method has an impact on reducing paperwork and space for storage of these materials. Documentation of activities involving purchases, sales, distribution, drug administration, patient health record, finance and other relevant activities of any organization is a primary issue in maintaining efficiency in operations (AHIMA, 2010). The use of paper documentation is somehow a far behind the method and rather tedious and inefficient. A more reliable and efficient way of keeping health records is thus a necessary change that may help reduce the demerits associated with the paper documentation method. Technologically advancement has brought with it more efficient and easy way to record and maintain a company or organization’s documents (AWARE, 2005). Changing from paper to electronic file documentation is thus a primary...
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...NURSING INFORMATICS LEADERSHIP Evaluation of Computerized Management Systems Kathryn Rawson Western Governors University Abstract This paper will demonstrate: A. How using computerized management systems could increase quality of care B. Why active nursing involvement in the planning, choice and implementation of the systems is important C. How handheld devices used by the nursing staff could be integrated into the management system for better quality care D. Security standards of data and patient confidentiality, including the need for data storage integrity and data backup and recovery and the Health Insurance Portability and Accountability Act (HIPPA) requirements impact the use of the systems E. How the new system can affect healthcare cost F. The benefits these new systems can offer to patient care and nursing care delivery with a recommendation and justification of the system the hospital should put in place In today’s modern healthcare environment it is important to provide a variety of technology based resources to nurses and other providers to ensure productivity and efficiency are maximized. This requires an effective understanding of available computerized management systems and what resources are available to ensure continued effective, efficient, quality care to patients. Keeping that perspective in mind while creating a technologically advanced environment in which to deliver that care is critical and of vital importance to...
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...NUT1 Task 1 Importance of Information Access using Electronic Medical Record (EMR): Electronic Medical Record (EMR) is a computerized system of keeping patient information. Similar to paper charting, EMR can be used to chart important patient data to treat patients and document the related nursing care. EMR can be used to store important patient information like patient’s diagnoses, allergies, medication, patient’s demographics, lab and diagnostic test. EMR also includes patient’s medical record number and account number that is given to the patients and is also used as reference about patients for future admissions. EMR’s provide accurate information that is easily accessible than paper charting. It also provides easy health care access to providers, improves communication among patients and health care providers. With EMR, nurses have easier access to in depth and detailed charting of physical assessment, tallying input and output and easy comparison in the trends of labs and diagnostic test. EMR also prevents medication errors since patients bar codes are scanned and verified accurately prior to administering medication. Data about medication is available prior to administration, so nurses can monitor possible side effects of medication. Thus charting patient information in real time or the ability to access results improves quality of patient care and increase co-ordination among health care providers. Personal Health Information: Personal Health Information (PHI) available...
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...Status I will be reviewing three specific areas dealing with medication management. They are the following with the correlating Joint Commission Standard following each one: 1. The hospital plans its medication management process, (MM.01.01.01). 2. Label all medications, medication containers, or other solutions on and off the sterile field, (NPSG.03.04.01). 3. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy, (NPSG.03.05.01). In review of standard MM.01.01.01, I see that Nightingale Community Hospital (NCH) has a policy that speaks directly to this standard. The elements of performance are met by the policy that is in place and includes further information to make this important standard compliant with Joint Commission standards. In review of standard NPSG.03.04.01, I do not find the NCH has a policy that addresses this. Seeing that NCH has surgical and sterile procedures performed at its facility this standard needs to have a policy in place. The basis of this is patient safety related to the five rights of medication administration; Right patient, Right medication, Right dose, Right route and Right time. Even in a controlled environment of a surgical suite, this is vital to any procedure performed. In review of standard NPSG.03.05.01, NCH has a very good policy that addresses the standard; however there are some elements of performance that are missing. These elements...
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...RTT1 Task 1 Nursing-sensitive indicators reflect the structure, process and outcomes of nursing care. These are measurable indicators of the quality of care provided to patients. Quality and/or quantity of nursing care can and does affect patient outcomes and the understanding of these measurements can assist in the planning and implementation of nursing care so that appropriate, quality health care with positive outcomes can be achieved. Poor performance on these indicators means not only is the quality of the care provided not good enough, but also they lead to longer, much more expensive hospital stays with poorer outcomes for the patient. Use of restraints for safety is, unfortunately, sometimes necessary. Options to explore first should be: Is there a family member that can come and sit with the patient to keep calm and safe? Does the hospital itself provide sitters in the room for safety? Can the patient be moved to a room closer to the nurse’s station so they can be monitored by staff? Does the hospital have a “niche” cart to keep their confused patients busy? When restraints are used, it is of utmost importance to release the restraints every hour for range of motion exercise and to turn the patient hourly to prevent pressure ulcer and DVT occurrence. More importantly, if a pressure ulcer is starting to form, it must be documented per institution protocol and the patient must be turned and kept off the site so the pressure ulcer does not progress. Although not addressed...
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...results shows she has metabolic alkalosis. In focused assessment, detailed nursing assessment of particular body system(s) connected to the current problem is required. One or more body system may be involved.Nausea and vomiting can ocurr due to different reasons like food poisoning,chloecystitis or intestinal obstruction..For the patient with vomitting,intially the health care provider need to pay attention to signs of dehydration. Like assessing monitoring blood pressure and observing for hypotension, skin turgour and mucous membranes changes (McCance, Huether, Brashers, & Neal, 2014). General Assessment: Patient had dark circles under the eyes. She looked worn out. She was feeling anxious. Her energy level was very low. She was speaking very slowly. Abdominal Examination: Abdomen is soft to touch. Patient has some epigastric pain. Bowel sounds are decreased.No bloating or acidity. Signs of hypo-motility may indicate an increased risk for nausea and vomiting. Cardiovascular system: Patient is hypotensive with tachycardia. No heart regurgitation or murmur. Heart rhytm is regular. Patient is feeling tired and dizzy. Pulmonary system: Patient is in metabolic alkalosis. Respirations rate is low 12 breaths per minute. Patient is taking deep regular breaths. Lungs are clear to ausculation. She has no shortness of breath or wheezing.No sign or symptom of any aspiration. Integumentary System: Patient‘s skin was pale and flaccid. Patient had dark circles under the...
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...Fall Prevention Falls are the leading cause of fatal and nonfatal injuries for persons over 65 years old. Falls can be linked to several factors such as several medical, cognitive and functional factors. There are several factors as well as situations that can increase fall risk such as unsteady gait, vision and cognitive impairment, incontinence and environment (Huey-Ming, 2011). In 2005, a sum of 15,802 individual over 65 years of age reportedly were injured from falling and died. In 2006, 1.8 million estimated individuals over 65 years old incurred some kind recent injury related to falls (CDC, 2006). However, the number of uninjured older adults that fell or had minor to moderate injury is unknown. The purpose of this paper is to discuss the issues of falls on the geriatric unit that I am employed and the changes necessary to decrease the numbers of falls on this unit. Problem Identification The geriatric unit in the hospital where I work has an average census of 36. On this unit patient falls are the most prominent problem. According to the hospital data in the past six months, there has been an average of two falls a day and twenty injuries related to falls. The number of patient falls has increased by 35 percent in the past six months. The goal of the fall prevention program is to reduce falls percentage by 30 percent (three falls a week) for the next three months and maintain it at a maximum of one fall a month thereafter. Falls affects the safety of the patients...
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