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Once the patient is admitted the provider alreadyhas the foundation to make more informed decisions increasing the patient’s probability of a better patient outcome. To ensure the most successful patient outcomes there needs to be gathering of accurate data, storage of trends and ability to see all relevant information to a patient, past and present. As an example, when a patient transitions from an ICU setting to floor status often things are forgotten in the transfer of that patient – either through nurse to nurse report or the transitioning of providers. When data is compiled electronically this allows for any provider to review all information to trend things such as labs, or vital signs. The information that can be trended or
INFORMATION MANAGEMENT – C791 8gathered is only as good as the documentation that is entered. Therefore, the reliability of the EHR system is crucial in assisting with a positive patient outcome. Quality Improvement DataQuality Improvement (QI) is at the forefront of discussions in most healthcare provider settings around the nation. EHRs offer opportunities to collect and analyze data — activities at the core of delivering quality patient care, preventing errors, and minimizing risk. Yet, the challenge for healthcare practices is understanding how to aggregate and evaluate the data, analyze the results, and develop strategies and initiatives that will help support quality improvement (QI) (Black, et al, 2011). When considering a new system or EHR, evaluating the tools that will aid in QI should be considered of the highest importance so that you can ensure measurable improvements or obvious declines. Data collected from all providers, as well as previous encounters gives providers more tools with which to measure improvement or decline. For instance, a patient presents with a chronic wound which has evolved into a systemic infection. During hospitalization, there is digital documentation of the wounds progression through treatment. Being able to see visually whether there is improvement or worsening can determine the need fora change during treatment as well as determine if the proper course is being implemented. This will not only impact care during the current hospitalization but will be able to be referenced during ongoing treatment moving forward. It provides an opportunity to see a starting point and determine if the treatment given is aiding or forbidding improvement. The correlation of the datacollected will enable the provider to determine the proper course of treatment moving forward. With regards to nursing’s relationship to the EHR, there are numerous processed in whichthe nurse interacts with the system for the benefit of the patient. There are times that the data
INFORMATION MANAGEMENT – C791 9entered sparks a need for clinical decision to be made. If a patient has a Foley catheter, documentation can be entered as to the necessity for the catheter and prompts the nurse to either continue the catheter or notify the provider of the need to evaluate the necessity.
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Electronic health record, Delivery of Care and Patient Outcomes