LITERATURE REVIEW: THE USE OF CLINICAL SYSTEMS TO IMPROVE OUTCOMES AND EFFICIENCIES

New technology—and the application of existing technology—only appears in healthcare settings after careful and significant research. The stakes are high, and new clinical systems need to offer evidence of positive impact on outcomes or efficiencies.

Nurse informaticists and healthcare leaders formulate clinical system strategies. As these strategies are often based on technological trends, informaticists and others have then benefited from consulting existing research to inform their thinking.

In this Assignment, you will review existing research focused on the application of clinical systems. After reviewing, you will summarize your findings.

To Prepare:

· Review the Resources and reflect on the impact of clinical systems on outcomes and efficiencies within the context of nursing practice and healthcare delivery.

· Conduct a search for recent (within the last 5 years) research focused on the application of clinical systems. The research should provide evidence to support the use of one type of clinical system to improve outcomes and/or efficiencies, such as “the use of personal health records or portals to support patients newly diagnosed with diabetes.”

· Identify and select 4 peer-reviewed research articles from your research.

· For information about annotated bibliographies, visit 

https://academicguides.waldenu.edu/writingcenter/assignments/annotatedbibliographiesLinks to an external site.

The Assignment: (4-5 pages not including the title and reference page)

In a 4- to 5-page paper, synthesize the peer-reviewed research you reviewed. Format your Assignment as an Annotated Bibliography. Be sure to address the following:

· Identify the 4 peer-reviewed research articles you reviewed, citing each in APA format.

· Include an introduction explaining the purpose of the paper.

· Summarize each study, explaining the improvement to outcomes, efficiencies, and lessons learned from the application of the clinical system each peer-reviewed article described. Be specific and provide examples.

· In your conclusion, synthesize the findings from the 4 peer-reviewed research articles.

· Use APA format and include a title page.

· Use the Safe Assign Drafts to check your match percentage before submitting your work.

LEARNING RESOURCES

Required Readings

· McGonigle, D., & Mastrian, K. G. (2022). 
Nursing informatics and the foundation of knowledge (5th ed.). Jones & Bartlett Learning.

· Chapter 14, “The Electronic Health Record and Clinical Informatics” (pp. 293–316)

· Chapter 15, “Informatics Tools to Promote Patient Safety, Quality Outcomes, and Interdisciplinary Collaboration” (pp. 323–349)

· Chapter 16, “Patient Engagement and Connected Health” (pp. 357–378)

· Chapter 17, “Using Informatics to Promote Community/Population Health” (pp. 383–397)

· Chapter 18, “Telenursing and Remote Access Telehealth” (pp. 403–432)

· Benda, N. C., Veinot, T. C., Sieck, C. J., & Ancker, J. S. (2020). 

Broadband internet access is a social determinant of health!Links to an external site.
. 
American Journal of Public Health, 
110(8), 1123-1125. https://doi.org/10.2105/AJPH.2020.305784 

· Dykes, P. C., Rozenblum, R., Dalal, A., Massaro, A., Chang, F., Clements, M., Collins, S. …Bates, D. W. (2017). 

Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study


 Download Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study
. 
Critical Care Medicine, 45(8), e806–e813. doi:10.1097/CCM.0000000000002449

· HealthIT.gov. (2018c). 


What is an electronic health record (EHR)

?Links to an external site.
 Retrieved from 
https://www.healthit.gov/faq/what-electronic-health-record-ehr

· Rao-Gupta, S., Kruger, D. Leak, L. D., Tieman, L. A., & Manworren, R. C. B. (2018). 

Leveraging interactive patient care technology to Improve pain management engagementLinks to an external site.
. 
Pain Management Nursing, 19(3), 212–221. 

· Sieck, C. J., Sheon, A., Ancker, J. S., Castek, J., Callahan, B., & Siefer, A. (2021). 

Digital inclusion as a social determinant of healthLinks to an external site.
. 
NPJ Digital Medicine, 
4(1), 52.  https://doi.org/10.1038/s41746-021-00413-8 

· Skiba, D. (2017). 

Evaluation tools to appraise social media and mobile applicationsLinks to an external site.
. 
Informatics, 4(3), 32–40. 

· Sharma, P., & Patten, C. A. (2022). 

A need for digitally inclusive health care service in the United States: Recommendations for clinicians and health care systemsLinks to an external site.
. 
Permanente Journal, 
26(3). https://doi.org/10.7812/TPP/21.156 

Details on reflection

Respond to Kaffy

Ensuring accurate and confidential documentation in nursing is crucial for patient care, legal compliance, and maintaining the integrity of healthcare records. However, nurses face several challenges in achieving this goal. Three prominent challenges include workload, knowledge, and complex documentation systems.

Firstly, nurses often contend with heavy workloads that can make it challenging to dedicate sufficient time to accurate and complete documentation. The demands of patient care, frequent interruptions, and the need to juggle multiple tasks can sometimes hinder their ability to maintain comprehensive records (Cimino, 2013).

Secondly, nurses need to possess a deep understanding of documentation policies, procedures, and the legal implications of inaccuracies or omissions in their records. Knowledge gaps in these areas can result in documentation errors that compromise patient care and expose healthcare facilities to legal risks (Cimino, 2013).

Thirdly, the documentation systems that nurses use can be complex and not always user-friendly. Navigating these systems effectively requires training and familiarity, and any difficulties in system operation can affect the accuracy and confidentiality of documentation (Cimino, 2013).

To overcome these challenges, nurses can take proactive steps:

Workload Management: Nurses can prioritize their documentation tasks and seek opportunities to delegate tasks when possible. Utilizing informatics tools can help automate certain documentation processes, alleviating some of the time constraints (American Nurses Association, 2020).

Knowledge Enhancement: Nurses should seek out training programs related to documentation policies, procedures, and legal implications. They can also collaborate with colleagues or healthcare professionals for guidance and clarification on documentation-related queries.

System Proficiency: To tackle the complexities of documentation systems, nurses should invest time in learning how to use them effectively. They can also report any system-related issues to their supervisors, advocating for improvements where necessary (American Nurses Association, 2020).

The integration of informatics into nursing practice can play a transformative role in addressing these challenges. Informatics tools can:

Automate Documentation: By automating routine documentation tasks like generating nursing notes or medication administration records, informatics can significantly reduce the time burden on nurses, allowing them to allocate more focus to patient care.

Provide Alerts and Reminders: Informatics systems can offer real-time alerts and reminders, ensuring that nurses complete documentation tasks in a timely and accurate manner. These cues can be invaluable in preventing oversights (American Nurses Association, 2020).

In summary, informatics offers a multifaceted solution to the challenges nurses face in documentation. By automating tasks, providing reminders, improving data access, and enhancing security, it empowers nurses to deliver more accurate, complete, and confidential documentation while mitigating the obstacles presented by workload, knowledge, and complex systems.

References

Nursing Documentation and Informatics: A Core Competency for Nurses. (2020). American Nurses Association

Cimino, J. J. (2013). Nursing Documentation: Informatics for the 21st Century. (4th ed.).

Respond to Muni

1.Data Accuracy and Completeness: 

Maintaining the accuracy and completeness of patient information is one of the biggest issues in nursing documentation. The many duties that nurses must complete may cause them to forget to record important patient information or cause mistakes. Keeping the record updated in real-time may also be difficult if the patient's health changes quickly.

Strong observational and documenting abilities would be needed to overcome this difficulty. Peer evaluations, training workshops, and regular audits of medical records can all be beneficial. Electronic health record (EHR) solutions offered by informatics can significantly contribute to the reduction of errors by automatically recording and updating some patient data (such as vital signs from connected monitors).

2.Confidentiality and Privacy: 

Maintaining patient data security In nursing practice, confidentiality is essential. However, problems might occur as a result of unauthorized access, data breaches, or even an inadvertent disclosure of private information during normal conversations.

Nurses can avoid this by properly following HIPAA rules and upholding their professional limits. Staff members should receive comprehensive cybersecurity training and should only access patient data when necessary. Data security can be strengthened with the use of informatics systems like EHRs, which can assist with access controls, encryption, and audit trails to trace who is accessing data.

3.Time Constraints: 

Due to their busy schedules and time constraints, nurses may struggle to accurately and swiftly record patient information. As a result, there can be a delay in recording or inaccurate data.

This challenge can be lessened with good time management techniques and delegating when appropriate. Informatics is involved once again in this situation. Technologies like speech-to-text software and electronic health records (EHRs) help speed up the documentation process and note-taking. Nurses can document data at the point of care more quickly with the use of mobile devices.

Keep in mind to comment on other entries and offer helpful criticism. To improve our collective nursing practice, we may all benefit from exchanging real-world experiences and solutions.

REFERENCE

· https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6111626/

· https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-019-4661-x

· https://www.nuance.com/asset/en_uk/collateral/healthcare/ebook/eb-nuance-nurse-clindoc-screen.pdf

· https://www.frontiersin.org/articles/10.3389/fcomp.2021.624555/full

Module 03 Written Assignment – Health History

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Module 03 Content

1.

Top of Form

This assignment is due no later than Sunday October 22nd at 11:59pm

Conduct a health history on a family member or friend. 
You can use the form located in your Health Assessment lab manual book or from Week Two classroom assignment. 

You do not need to submit the health history form with your paper.
 Be sure they give you permission. Using the interviewing techniques learned in Module 2, 
gather the following information. Use your textbook as your guide.

· Present Health

· Past Medical Health

· Family History

· Review of Systems

 

While this is only a partial health history, summarize in 3 -5 pages the information you gathered.

Include your answers to the following questions in the summary:

a. Was the person willing to share the information? If they were not, what did you do to encourage them?

b. Was there any part of the interview that was more challenging? If so, what part and how did you deal with it?

c. How comfortable were you taking a health history?

d. What interviewing techniques did you use? Were there any that were difficult and if so, how did you overcome the difficulty?

e. Now that you have taken a health history discuss how this information can assist the nurse in determining the health status of a client.

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Unit 3 Discussion – ICD-10 Codes. Due 7-25-23. 1000words. 4 references

1. Why is accurate coding using the ICD-10-CM important?

2. Use your lecture materials to determine what ICD-10 Codes to assign for this patient encounter.

3. In paragraph form, construct a discussion that supports the Codes you identified. 

4. In the discussion explore how the ICD-10 Codes that you assigned impact third party payor reimbursement for this visit.

5. Summarize an article that pertains to ICD-10-CM

Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.

Please review the rubric to ensure that your response meets the criteria.

Chief Complaint:

Older sister reports – “Our mother died three weeks ago and we lost our father several months ago. I think that my sister was depressed and just wanted to be with them.”

History of Present Illness:

31-year-old female who was brought to the hospital by ambulance. She was found slumped over in her car in front of the funeral home where memorial services for both her father and mother had recently been held. On the seat beside her were two empty bottles of sleeping pills, a Bible opened to Psalm 23, and a note that read
: “I am going to be with mom and dad. It is just too sad being here anymore without them. I love you all and you will be in my prayers.” When she was found by the funeral home director her hair was oily and unkempt and she smelled as if she had not bathed in a long time. She was wearing a dirty orange T-shirt and jeans.

PMH:

Depression when she was a junior in HS which led to psychiatric admissions at 15 and 19 years of age. For these admissions she was treated with antidepressants and psychotherapy. Length of stay for both admissions was approximately 5 weeks. At age 19, following a suicide attempt, she met her first husband in the psych ward of the hospital. Diagnosed with bipolar disorder 6 years ago.

Information from Sister:

Older sister reports ‘hard life’. Reports both parents were alcoholics. Parents would go to bars almost every night and leave the 8 children in the care. The children were eventually removed from the home. Some of the children went to the Catholic girls’ home others were placed in “horrible” foster homes where they were subjected to physical and sexual abuse.

Reports numerous siblings, including the patient, have been through several detoxification centers for alcohol abuse.

Patient is in her second marriage with 3 daughters – 2 from the first marriage and 1 from the current marriage.

Reports that after having her third baby the patient went into a ‘terrible depression’. The patient was under the care of a psychiatrist for this depression and was placed on an anti-depressant after about 3 months of being under the psychiatrist’s care. After 3 weeks of being on this anti-depressant the patient is reported as having gotten ‘really weird’; patient was staying up all night pacing around her house and talking to people on the phone, she would go on shopping sprees for 2-3 days at a time and max out all her credit cards. The patient finally crashed and was taken to the hospital by her family and it was during this admission, 6 years ago, that the patient was diagnosed with bipolar disorder. Sister reports the patient has been on Lithium since being diagnosed with bipolar disorder.

Reports their father had been sick for a while so his death was not unexpected. However, their mother went downhill fast and the patient is reported to not cope well with the mother’s illness/death.

Reports the patient hadn’t been eating lately with noted weight loss. Additionally, the sister reports the patient had been smoking and drinking ‘more than usual’ lately.

Family Hx:

Paternal grandmother – depression

Two maternal aunts – bipolar disorder

Mother and father – alcohol abuse

Father died from pancreatic cancer

Mother died from heart failure

3 living brothers, 3 living sisters, one deceased brother who had an AMI at age 34

Social Hx:

Divorced and remarried

Worked as a nurse’s aid and health insurance claims adjuster

Attends church regularly

Smoked 1ppd for 15 years

History of alcohol abuse with several DWI violations

History of IV drug use, not in the last 10 years

ROS:

Information from sister:

Neuro – history of migraine headaches since late teens, takes Imitrex prn

SIGECAPS:

Sister reports: at times the patient is up all night – particularly when bipolar symptoms not well controlled, the patient seemed to be more depressed since the loss of their mother, does not believe the patient felt guilty surviving parents, patient has been not been attentive to her personal hygiene, the patient appeared to be obsessing on parental loss, patient appeared to be losing weight and therefore suspect she was not eating well, patient seemed to not be engaging in typical daily activities; patient had not expressed having suicidal ideations, had not expressed homicidal ideations

Medications:

Lithium 600mg po Q AM and 600mg po Q HS

Sumatriptan 50-200mg po PRN

Allergies:

ASA – swelling of face

Physical Examination:

General – lethargic and slow to respond to questions; BP 110/72, P 66, RR 12, T 97.0, SpO2 on RA 95%, Ht 66 in, Wt 135 lbs, BMI 21.8

Integument – skin pale, warm, dry; good turgor; several cystic lesions on chin; no rashes, ecchymoses or petechiae noted

HEENT – Head is normocephalic and atraumatic, pupils dilated with sluggish reaction to light, TMs gray and shiny bilateral, nares patent without discharge noted, no tonsillar enlargement, moist mucous membranes

Neck – supple without adenopathy, no thyromegaly

Lungs – CTA

Breasts – deferred

Cardiovascular – heart with RRR without murmur/gallop, multiple varicosities noted bilateral lower extremities

Abdomen – soft, non-distended, active bowel sounds, non-tender, no organomegaly

Genitalia/Rectum – deferred

Musculoskeletal – no major limitations of ROM or gross abnormalities noted

Neurologic – oriented to person, DTRs 2+ and equal bilateral, no localizing signs, CN II- XII grossly intact

Diagnostics – Na 139 meq/L, K 3.7 meq/L, Cl 108 meq/L, HCO3 23 meq/L, Bun 10 mg/dL, Cr 0.7 mg/dL, fasting Glu 102 mg/dL, Ca 8.7 mg/dL, PO4 3.2 mg/dL, Protein 4.8 g/dL, Mg 2.0 mg/dL, AST 33 IU/L, ALT 20 IU/L, GGT 82 IU/L, Alb 2.9 g/dL, TSH 4.1, Vit B12 203 pg/mL, Hgb 12.2 g/dL, HCT 36.8 %;

Lithium 0.08meq/L

Urine dipstick – 6.3 pH, SG 1.021, all other parameters negative

Assessment:

You will be evaluating the subjective and objective data sets to determine the diagnoses for this patient encounter.

Plan:

The plan cannot be developed until the diagnoses are assigned.