Clinical Documentation System
Abstract
Clinical Documentation System (CDS) is essential to the process of creating and transmitting a broad range of medical documents, usually with a advanced level of automation. The medical documents include Allied Health notes, Pharmacy updates, Discharge Summaries, Patient Progress Notes, and Admission Notes. The Clinical Documentation Systems christened Point Click Care (PCC) is one of the most popular Electronic Health Records for long-term care. Point Click Care plays a critical role in the management of a comprehensive lifecycle of resident care. The paper mainly focuses on the System and Setting Description, Data Collection and System Analysis, Safety and Outcome Analysis, Evidence-Based Practices, and Collaborations.
System and Setting Description
Describing the System and intended use/functions
The Clinical Documentation System seeks to enhance proper integration of medical data from a range of existing information systems to improve precision and completeness. Most of the modern heath care facilities have adopted the system to facilitate service delivery. Nurses and nurse administrators design the system in collaboration with various clinical representatives drawn from units such as Respiratory Therapy, Discharge Planning, Social Services, and Physical Therapy among others. Point Click Care provides long-term solution to documentation problems, which has hampered delivery of services in various health care facilities (Electronic medical records 2011). The integrated system of Point-Click- Care streamlines administrative, billing, and clinical processes. Since the system generates clear and typed documents, medical error, inattention or the general confusion that characterize manual documentation system are negligible. Point Click Care would also ensure proper coordination of activities and data from different departments. Thus, it becomes much easier to assesses and evaluate the performance of every department toward achieving the common goal which is to assist long-term care providers administer the lifecycle of resident care through their web-based solutions. Other objectives of the documentation system are to improve clarity as well as accuracy of documentation. Although the entire documentation process might face enormous challenges such loss of document and low pace of document processing, integration through its Electronic Health Record (HER) provides solution to such problems (Electronic medical records 2011).
Types of Settings and Clients Served
Point Click Care’s exceptional services have attracted clients from different settings across Canada and United States. Apparently, the corporation mainly deals with larger health care facilities and caregivers. The clinical documentation department of the facility should be willing to embrace the Electronic Health Platform (EHR). In essence, Point Click Care does not offer services to care providers who still rely upon the manual documentation systems. Majority of its clients are care providers whose main reason for seeking electronic health record technology is to find long-term solution clinical documentation issues. Care providers whose motivation revolves around solving clinical documentation issues may find Point Click undesirable or simply costly to them. Since the documentation technology firm only operates in Canada and the United States, clients from outside the two territories would find PPC undesirable choice for solving the clinical documentation problems (Electronic medical records 2011).
Data Collection and System Analysis
Description of how and when the data is collected
The technology hub of clinical documentation collects data from various departments within the facility. The data, which is manually stored, then converted to Electronic Heal Records. Point Click Care employs its vast experience and range of software to actualize the electronic storage system. Once the information has been stored electronically, unauthorized persons cannot access it. Apart from obtaining data from the care provider’s document files and data bank, the electronic documentation firm may also rely on information from other hospital systems as well as the previously created documents. This will in effect ensure the electronic data system of a single client meet the expectation and objectives of the client. The firm collects data on demand from prospective clients (Life sciences 2008). A number of clients (care providers) would prefer hiring the services of PCC when they intend to go electronic from the traditional manual documentation. The care providers would also seek services of the technology firm whenever they are facing the challenge of keeping the records of a surging number of patients. The sudden increase in the number of patients seeking medical attention in facilities in the United States and Canada may also prompt the facility’s administrator to seek PCC services. This will enable them accommodate the huge volume of data which the care provider is incapable of managing through its manual documentation system (Life sciences 2008).
Identifying the data users and retrieval method
The facility management would be the chief recipient of the electronic data stored by PCC. The data would be fundamental for planning, policy implementation, and budgetary measures. In terms of planning, the information available through electronic systems would be instrumental for taking measures such as expansion of facility infrastructures, regulating the population of medical staff, and purchasing equipment as well as pharmaceuticals (McGonigle & Mastrain, 2012). Government agencies mainly drawn from the department of health and sanitation may also use the data for policy implementation purposes and assessing whether the care providers have met the threshold or standards governing operations, service delivery, and the health sector in general (Life sciences 2008).
Analyzing if the system functions as intended
The system has always met the expectations of its wide range of clients in Canada and United States. Despite the extensive coverage of US and Canada, a growing number of care providers in other continents have attempted to secure the services in vain. Caregivers in these two countries had the opportunity to secure their documents through the electronic system (Electronic medical records 2011). Retrieval of such documents has even become much easier considering many caregivers had previously expressed reservations about the difficulties they have encountered when retrieving clinical documents through the manual system. However, the firm has successfully unveiled its massive programs in different places within the territories of the two countries and has a plan to open branches in other countries in future (Electronic medical records 2011).
Analyzing if the system supports the work of clinicians
The electronic documentation system provided by PCC supports the work of clinicians. In the wake of plans initiated by governments and private sector to hire more clinicians has, health care has emerged as one of the key priorities (Electronic medical records 2011). In effect, different care providers and state agencies have injected into the sector colossal amounts of funds to support expansion of existing facilities and establishment of new ones. The demand for clinicians has definitely gone up prompting the administrators of such facilities to hire PCC to uphold documentation processes, which has made works of clinicians much easier (Electronic medical records 2011). It is high time clinicians embraced the modern technology by making sure they computerize the documentation process.
Description of how the system supports patient safety and safe care environments
Point Click Care is an electronic medical record. In addition, it makes documentation of records easy and efficient. The system helps in supporting patient safety and provides a safe care environment. The safety of patients increases by using the system. There are ways that this happens (Obiero 2009). Through proper and adequate documentation, the quality of care that patients receive will increase. This, in turn, will promote the safety of all the patients in the hospital. Point click care ensures that all the documents about the health of a patient get documentation. The lack of documentation about the patients’ records leads to the endangering of the patients’ health.
Point click care ensures that this does not happen. Point click care ensures that there is good documentation, which in turn ensures that patients receive the best possible care from the doctor and from the health provider who relies on PCC for documentation (Life sciences 2008). PCC ensures that incidents of duplication do not occur. This helps when a hospital refers a patient to another hospital. Proper documentation will enable the new doctor to know all the medical care that the patient received from the previous hospital (Electronic medical records 2011). Good documentation using point click care ensures that there is the prevention of unnecessary medical services. This ensures that patients are not in harm’s way through treating the patients basing on incorrect information.
Analysis of the impact the system has on improving client outcomes
There are more benefits associated with using point click care than there are disadvantages. One of these main benefits is that it leads to proper and good outcomes when considering the health of the patients. Research shows that the patients whose records handled using point click care received accurate and professional medical care than patients who did not. Improved medical care that results from professional documentation leads to good outcomes when considering the health of patients (Obiero 2009). The system also leads to proper customer satisfaction. This occurs since the patients get treatment for what ails them.
The system also ensures that patients receive treatment at a fast rate. The faster the patients get treatment the faster they get well (Life sciences 2008). The system processes documents at a fast rate ensuring that doctors do not delay in treating patients. This leads to customer satisfaction and the improvement of client outcome.
Strengths and limitations the system has on supporting clinical decision making and promoting quality outcomes
There is more strength that the system has in supporting clinical decisions than there are limitations. The system supports clinical decisions by ensuring that doctors engage themselves in quick decision-making processes. The system provides quick admission, discharge and the transfer of information from the clinical software in the hospital (Electronic medical records 2011). Quick and accurate decision-making in the hospital lead to quality outcomes. PCC enables doctors to handle the complex challenges of managing the electronic health records. The system also ensures hospital personnel keep business records of hospitals in a professional manner. The system has another key advantage.
The system leads to streamlined management of information. This results to improved efficiency in the staff. It also leads to accurate documentation of information and accurate data transfer. All these benefits play a key role in ensuring quality outcomes in all the activities of the hospital (Obiero 2009). The main limitation to the system is that hospital personnel charged with the management of records need to receive prior training. For a person to use the system correctly, he or she must be aware of the system and should know how to use it in an accurate and precise manner.
Explain how the data collected from this system can support and serve as the basis for the development of Evidence Based Practice standards of care and clinical practice guidelines
Evidence Based Practices of care are recommendations for clinical care supported by evidences in clinical care. Clinical practice guidelines are statements systematically developed for the assistance of practitioners and patient decisions. These statements provide appropriate and concise health care for clinical conditions. The Point Click Care system ensures that creation and documentation of records is unbiased and transparent.
This offers a clear guideline to clinical practice since the system offers a systematic review and appraisal in the highest quality. The use of the system ensures that there is no bias in information. This ensures the elevation of information, which is transparent. This leads to improved quality care. The data collected and documented by the system is free of bias and thus works as a foundation for the development of evidence based practice standards.
Description of how the information generated by the system is or could be shared across healthcare disciplines
One key role of the system is to help in the transfer of information at a fast rate. The system helps in the cross-reference of sections in the MDS assessment. This encourages collaborative interaction while engaging in decisions for care planning. The system ensures that the hospital staff collaborates since there is a flow of information. This ensures that the staff does not feel in isolation and can complete assessments of patients and can share information freely. Quality care occurs by the sharing of information since all the disciplines know what a patient requires and how best to treat the patient.
Explanation of how the multidisciplinary exchange of information promotes collaboration and continuity of care
For the effective care and treatment of patients in the hospital, there should be a system where information can pass freely and fast to all the departments. This ensures that all the departments in the hospital work, in unison. Availability and exchange of information has immense benefits in the continuity of care. Collaboration between doctors and other staff members ensures that they work in an effective manner to the treatment of all patients in the hospital.
References
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Obiero R. PointClickCare. (2009). http://www.maintenancecare.com/images/Kensington_casestudy.pdf
McGonigle, D. & Mastrain, K. (2012). Nursing Informatics and the Foundation of Knowledge, Sudbury, MA: Jones & Bartlett Publishers
