Hospitals with computer system that allows for electronic clinical documentation estimation is 71.5%. (Agency for Healthcare Research and Quality, n.d.) “The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs” (Lavin, Harper & Barr, 2015) All staff members are required to use the Armed Forces Health Longitudinal Technology Application (AHLTA) as source of documentation. A solid back up process has been established if computer access is compromised due to network problems. Likewise, when patients receive specialized care at network medical facilities, a method for scanning those results into the EHRs has been established and vigorously enforced. One of the National Patient Safety Goals is the identity patients correctly. Use t lease two patient identifiers when providing care, treatment, and services. (The Joint Commission, 2019) MHS no longer uses social security numbers as the primary method for patient identification. The facility utilizes name and date of birth as method for patient identification. Also, patients were assigned an arbitrary 10-digit number. These identification options help to ensure correction medications and care is rendered. This system was established to reduce security risk that could severely affect the patient population in event of a computer security breach.
ESSENTIALS OF ADVANCED NURSING PRACTICE Evaluation of Change Effectiveness The Agency for Healthcare Research and Quality has a sample Healthcare IT Evaluation toolkit. Two of the recommendations includes monitoring verbal orders and coding. (Agency for Healthcare Research and Quality, n.d.)To access the impact of increased electronic documentation an evaluation of coding accuracy and percentage of verbal orders. Monitoring coding will be access for accuracy and documentation supporting care rendered during appointment. Monitoring the percentage of verbal orders will allow the facility to measure whether verbal orders are trending down with the use of electronic documentation. HCIs performed a record reviews. Each month each discipline performs random electronic health record documentation review of their peers. A specified number of EHRs are reviewed with specific areas of focus. The results of these monthly EHRs evaluations are provided to respective nurse manager. The data collected will be examined to identify trends. Nurse Leader Interview Verification Form
ESSENTIALS OF ADVANCED NURSING PRACTICE Conclusion Nurses are essential to maintaining quality and safe health care. According to the American Association of Colleges of Nursing (2011): A masters prepared nurse must be articulate in the methods, tools, performance measures, culture of safety principles, and standards related to quality, as well as prepared to apply quality principles within an organization to be an effective leader and change agent.
- Fall '18
- Health care provider, Military Health System