Clinical Documentation Essay

2727 words - 11 pages

Clinical Documentation System
Excelsior College
October 6, 2013

Clinical Documentation System

Clinical information system (CIS) collects patient data in real time, stores healthcare data and information using secure access to the healthcare team.  (McGonigle & Garver Mastrian, 2012, p. 554).  The CIS that is used at Texas Health Dallas is CareConnect.  CareConnect is used by all of the Texas Health Resources (THR) encompassing 25 hospitals, affiliated physician offices, and ancillary facilities.  CareConnect allows physicians and management to access the system on their mobile devices and home computer for real time data.  The shift for CIS is set for ...view middle of the document...

  For example, there are specific tabs set up for medications, patient history, results, and orders.
The CareConnect system functions as it is intended to as it allows the clinical staff to obtain the data entered, and promote a care plan based system which focuses on the diagnosis of the patient.  CareConnect provides an organizational tool for the nurse to be able to update and enter data on an ongoing basis, as well as, making it possible for multiple users to access a specific patient’s chart simultaneously.  All information is centralized which allows the healthcare team access and prevent redundant testing. This system allows for orders and patient specific data to be clearly written which avoids the concern of illegible handwriting risking potential error.
“Workflow analysis is a study of the way documents, information and people related to a process move through an organization, in order to improve efficiency.” (Wilkerson-George, Roark, Turner, Urby, & Kerr-Kanabec, 2011, p. 8).  CareConnect supports workflow by the ease of use when charting patient data.  For example:  when a patient arrives in the emergency room, the patient is triaged using the triage tab. This prompts the nurse to enter all required documentation during this time as directed by “best practice” standards. Best practice standards are the required screening tabs such as fall scale, suicide screening and immunization screening. Next order sets for a given chief complaint are selected and the physician selects specific patient orders.  Order sets can be defined as labs, diagnostic studies and nursing interventions for that particular complaint.  For example: a patient presents with chest pain, the order set includes:  Chest x-ray, EKG, CBC, CMP, Troponin, continuous heart monitoring and pulse oximetery.  The next step involves assigning to a room and physician then signs up for the patient then reviews patient information via the navigator selection.  The navigator will allow healthcare team to see what interventions that have been completed since the time of arrival which includes actual patient assessments, vital signs, general notes, and all procedural and laboratory data.  All staff in the emergency room uses the ED navigator as it is updated on a real time basis.
One way THR has implemented safety for patients is through documentation tool called Safety Action Learning Tool (SALT).  Risk management, quality, performance improvement and patient safety use the SALT for data collection.  The SALT is not part of the medical record but is part of data collection process.  CareConnect has some safety implementation built into patient assessments; an example would include the fall risk scale.  Patients are screened for a falls at the time of admission, during each shift, with any acute change in condition, and at discharge. If it is determined the patient is a high fall risk, the nurse is then prompted to implement fall risk interventions, which sets the stage for...

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