Clinical Information System: Clinical Documentation System

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 implementation throughout the United States
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 ongoing risk assessment. The process of completing an incidence report is recorded when a fall or near miss event occurs by the person reporting using the SALT tool. Other data collected under the SALT system would include number of acquired nosocomial infections while hospitalized. By having this assessment tool complies the entered data from which some of the information must reported, thus, affecting reimbursement
One type of error in the ER is the possibility for a physician to place orders in the wrong patient’s chart. Physicians are often responsible for more than 20 patients at a time, as well as, supervising the physician assistant’s patients as well. Good care coordination between the nurse and the physician is a key component to assure orders are written on the correct patient and noting discrepancies as they arise. The nurse needs to thoroughly review orders ongoing for updates and question entries inputted by the MD. Even with systems ability to note discrepancies and providing pop up screens for healthcare workers, the potential for human error occurs when clinician has the ability to override warnings. The pop up warnings can be useful in prompting the healthcare worker to critically think, but can also cause harm to the patient if the clinician does not take the warning into account. Quality outcomes are measured by the reports that the safety and compliance auditors receive based upon reviewing data, thus, allowing the information to shared with staff in education sessions. “Meticulous testing of electronic healthcare record (EHR) products is critical to their safety.”(Hoffman & Podgurski, 2011, p. 79). In-services throughout the year to point out system updates are necessary for the CIS to be progressive and for the clinical staff to be made aware of changes. If a