NR 360 Week 4 Edapt; Professional Health Communication and Documentation of Care

Professional Health Communication and Documentation of Care Informatics and Communication Introduction to Informatics and Communications Informatics and communications work together to ensure access to important information whenever and wherever the client requires it. For this communication to be successful, computers, networks, and people need to be able to interact with a goal of interoperability. We also want to ensure high-quality information is exchanged between and amongst systems, providers, and clients. Because there are so many types of computer and communication systems, and because some of these systems have a global reach, consistency in standardized terminology and information exchange is essential. 914400177715 The HITECH Act was developed to promote and expand the use of health information technology, specifically, the use of electronic health records (EHRs) by healthcare providers. The act encouraged hospitals and other healthcare providers to make the change from paper records to EHRs to improve efficiency and care coordination. The other options do not specificially address EHRs. Effective communication in a high-tech environment promotes client-centered, quality care, client safety, prevention of adverse events and to improve health outcomes. It does not promote medical errors but aims to prevent them through clear communication efforts. Meaningful use (not minimal use) of health information, use of electronic health records, use of information exchange systems, and interoperability are ways to improve communication in a high-tech environment. Limits to information sharing can decrease our communication efforts aimed to promote communication and healthy outcomes. 914400178023 Informatics and Communication Communication between systems, providers, and clients is essential in health care organizations to support and improve health outcomes. The quality of systems and information exchanged is only as good as its interoperability and the quality of information it contains. The ability to find accurate information within the electronic health record (EHR) for both patient and provider can be hindered by lack of accurate information. “Perhaps the greatest challenge for both patients and providers is identifying information that is high-quality and which enhances (and does not impede) their interactions.” (Snyder, et al., 2011, p.211). 1186107167762 Data Integrity One challenge of the increased use and availability of electronic health systems is the amount of data that flows through the system. Additional concerns include how that data is collected, vetted, and stored. Case Study: Wilma, a medical assistant, is gathering information from Sam, a client of Dr. Goya who is here for a blood pressure check-up. Sam’s medication list includes atenolol, metoprolol, propranolol, and furosemide. When Wilma asks Sam if he still takes these medications, he replies, “I take whatever Dr. Goya prescribes for me.” Wilma smiles and documents “no medication changes” in Sam’s electronic health record (EHR). When Dr. Goya reviews Sam’s current medications, he is concerned that Sam is taking three similar drugs for hypertension and asks Sam about it. It turns out that after Dr. Goya prescribed metoprolol, which his insurance does not cover, so alternatively, atenolol was prescribed. The pharmacist called the office to request propranolol since atenolol was recalled by the manufacturer. Luckily, Sam’s partner