Clinical Documentation

Topics: Health care, Health care provider, Patient Pages: 8 (2670 words) Published: October 15, 2013


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 by 2015.  The clients served are those in the community that THR provides healthcare services to.  The electronic health record is shared amongst the healthcare team and other affiliates. Data collection can be continuously updated, used for “statistical evaluation for purposes of quality improvement, outcome reporting, resource management, and public health surveillance.”(Yamada, 2008, p. 5). Data collection is generally initiated in the ER, and other times when the patient is at the physician's office or in the outpatient service line.   To reference inpatient services, data collection begins in the ER.  The patient's allergies, current medications, medical history, vital signs, immunizations, suicide screening and domestic violence screening are all obtained upon the patient's arrival to the ER.  The gathering of this information, initiates a process for interdisciplinary data collection.  All healthcare team members can access a patient’s previous visits whether it is outpatient, inpatient, diagnostic or office visit.  Labs and radiological tests are shown by date and time and are listed in chronological order. The clinical staff member logs into the system, selects their patient using a tab-based system, which allows for the clinician to retrieve the data they are searching for.  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...

References: Hoffman, S., & Podgurski, A. (2011). Meaningful Use and Certification of Health Information Technology: What about Safety?. Journal of Law, Medicine & Ethics, 77-80. http://dx.doi.org/doi:10.1111/j.1748-720X.2011.00572.x
McGonigle, D., & Garver Mastrian, K. (2012). Nursing Informatics and the Foundation of Knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning. Retrieved from
Wilkerson-George, J., Roark, T., Turner, R., Urby, R., & Kerr-Kanabec, K. (2011, January 21). Tips On Workflow Analysis During an EHR Implementation [Webinar]. U.S. Department of Health and Human Services, 1-53. Retrieved from http://www.hrsa.gov/healthit/toolbox/webinars/pdfs/workflow.pdf
Yamada, Y. (2008, July 1). The electronic health record as a primary source of clinical phenotype for genetic epidemiological studies. Genomic Medicine, 21(1-2), 5. http://dx.doi.org/10.1007/s11568-008-9021-1
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