Clinical Documentation System Functions



Introduction2

System and Setting Description2

Data Collection and System Analysis3

Safety and Outcomes Analysis5

Evidence-Based Practice Outcomes using System Data6

Collaboration and Information8

References10

Clinical Documentation System Functions

Introduction

The clinical documentation is the process of providing care to the patients by collecting and communicating all essential information of the patient and treatment. This is achieved by maintaining a patient medical record that is used as the source of information among all the members of health care. Thus, considering the importance of this clinical documentation, it is important that the system of documentation is effective, complete and credible (Ross-Kerr 2003).

The patient care delivery process generates a comprehensive medical record. This record includes basic patient demographics like age and sex, information on diagnoses, procedures and treatments provided diagnostic test and results, medication use, and provider referrals. The American Recovery and Reinvestment Act (ARRA) of 2009 provided substantial funding to meaningful use and promote health information technology. The Act stated the completion of electronic health record of all Americans by 2014 as its goal. Using information technology and online applications helps in assessing the quality and reporting parameters. The new approaches focus on quality rather than the volume and intensity of service provided. It helps in improving provider payment methods and benefits designing. All of these activities ultimately provide better feedback for decision making in patient care (Engelberg Center for Health Care Reform, 2010).

System and Setting Description

The clinical documentation system in this assignment is implemented in the care settings where the patients' influx in the care services is very large. Also the settings are such that patients' demographics and problems differ at wider level. Clients served under such setting are those who require treatment for minor as well as chronic health conditions. Thus, the care providers working in the setting range from general physician to specialized surgeon.

The clinical documentation system is used in the practice settings where the electronic file of information is termed as the health or medical record of the patient. This information includes the assessment data, medication orders, clinical interventions, care plans, consults, nursing histories, laboratory data, and client outcomes.

There are two primary functions of clinical documentation systems which are to communicate relevant clinical information between various stakeholders involved in care process and to ensure compliance. It is necessary to communicate information among health care providers as they are separated by distance and time (Turisco & Rhoads, 2008). Also it is important to ensure compliance with the laws and regulations.

Data Collection and System Analysis

In order to ensure effectiveness of outcomes from this clinical documentation system, it is critical to ensure that data collection and analysis methods are highly competent. The clinical documentation systems use well designed computer applications through which data is collected in the standardized way. For ensuring all information relevant to the care, standard templates or customized screens are used that have drop down menus for guidance. The nurses are prompt to enter data in the system that is relevant to patient ...