A Clinical Documentation System and Data Collection

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Table of Contents

System and setting description
Data Collection and System Analysis
Safety and Outcomes Analysis
Evidence based practice and support
Collaboration and Information
References

System and setting description

A clinical documentation system is an organized system of information sharing in health centers. Through this system information is collected from the patients by the health care personnel; including both doctors and nurses then stored for future use whenever necessary. The information should be stored in such a way that it is easily accessible to the interested parties where and when required. The information may be provided to researchers and government officials for analysis during planning, in addition to the use by the patients for treatment and management during decision making.

Relevant security details like authorization procedures and use of security codes should be put in place, to ensure availability of adequate security in the system. This guarantees that, the information is safe from data base hackers in the internet and other malicious users. The system should be able to facilitate easy and efficient sharing of information with other systems. The movement and retrieval of the information by other departments from the system during daily operations must also be convenient and appropriate. Furthermore, relevant security protocol and details must be consistently observed (Burke, 2006).

The scheme should be able to provide order and organization to the institution. This is enabled through a well formulated and organized system which facilitates quick and efficient accessibility, reliability and storage of information. Besides, the information can be stored for a very long period of time after which, it will still be in a good condition for any meaningful use. The system replaces the cumbersome scenes of files, arranged on shelves that take a lot of space in the office. It further provides a clean form of data filing without waste papers to be burnt.

Another advantage is that, this system is dynamic enough to allow for the development of more advanced storage systems and software. This form of arrangement further provides an allowance for expansion. Anytime the institution has the need to expand storage facilities, due to an increased volume of work it becomes very easy. It can also accommodate new or addition of more efficient technology, as the system is compatible to the new development without addition of unnecessary costs. In big and well organized modern companies, the system is updated after very three years to accommodate any new technologies (Dudeck, 1995).

This kind of system is used in the medical setting in hospitals, dispensaries and health care centers. Its major functions are the collection of patients’ details and disseminating of appropriate medication to the prescribed patients. Most of the clients served in this setting are patients suffering from various medical conditions like fever, heart attacks, dysentery etc.

Data Collection and System Analysis

Data collection is among one of the most important functions of an information system in any institution. This is because the timing, nature and methods through which the information on patients is collected is very important in determining the reliability and accuracy of the collected information. Besides, forming a complete system that is working and faultless in any institution can be very tricky for most of the management. This is because the task is time consuming, detailed and sometimes complicated especially in large institutions due to the complexity resulting from numerous rules and policies governing such institutions.

In current medical systems, the information is usually collected and recorded during the interviewing of the patients when they first visit the institution. The physician may take sketch notes of the patients’ symptoms. The details in the notes are then used to make diagnosis and medication is then prescribed by the physician. The personnel later feed this information to the computer and into the institution’s database (Burke, 2006).

However, some patients may have complicated or acute medical conditions that might require observation for a while before reports are made on their condition. Due to these complications, they are admitted in the institutions wards where they are observed for sometime by an assigned doctor. In medical institutions, the personnel who mostly use the information are the nurses, who always get it from the patient’s files in the database or researchers who have to first seek for permission from relevant authorities in the institution.

According to how the data is used and the efficiency of service delivery in these medical institutions, it is clear that the system functions in the intended way. Although sometimes the resources for financing all the required facilities may be limited affordable methods are used. Some of the rooms that keep equipment and this information are locked up most of the time. This ensures up to date security precautions are observed in the institution. The information is made easily accessible to the nurses and anyone who needs it in the right protocol and for the right use (Burke, 2006).

The position of the computers location in the receptions and major offices of the institution ensure maximum accessibility and efficiency. Furthermore, the system is also automated such that input data by one individual can be immediately accessed by the other staff members. The automated system ensures high levels of efficiency by the staff and saves time due to the ease of information accessibility (Dudeck, 1995).

The system disseminates and keeps information appropriately and conveniently making it completely reliable. In large institutions with a lot of data, system analysts are employed for making sure that the information is well input and stored. They further use statistical methods like correlation and use of graphs and charts to present and store data. However, in the modernized institutions they have adopted the use of modern technology where the system makes use of an automated system analysis. This type of systems makes use of analysis software that is custom made for that purpose to make their work easy.

Safety and Outcomes Analysis

The automated nature of the system ensures that the patients are served the quickest way possible; this minimizes chances of premature deaths due to delayed treatment. In institutions that lack automated systems the patients have to wait in long queues, where some of them succumb to their pain. As a result of the efficient service delivery by the system to the clients’ continuity or loyalty is guaranteed. In the long run, there is client satisfaction with service delivery and build up of goodwill for the service provider (Falletta, 2005).

On the other hand, the patient’s information is secure, and patient confidentiality in accordance to the law is ultimately observed. In some sickness cases, like patients with terminally ill conditions; the hospital complies with those patients’ request for complete confidentiality even from the family members. In the event that the data is to be used for research, the subject of the source of information is recorded as anonymous. Those steps are taken to prevent the identity of the patient in question from the social stigma and other problems associated with the public exposure of the patient’s image.

In supporting clinical decisions the system ensures speedy information processing that improves service delivery. The system is also secure and systematically operating within a given protocol, which facilitates discipline among employees. The institution is thus able to maintain a given level of quality on their services and achievement of desired standards in the institution. In case of any emergency the system can adequately provide necessary information on the patients as the backup data is there and can be easily accessed (Falletta, 2005).

However, the system exhibits some disadvantages like maintenance costs. From time to time, the system may require to be upgraded, either to improve efficiency or capacity due to an increased customer base. This will automatically add up on the operational costs. Secondly, due to the automated nature of the system it may lead to the loss of employment for some of the employees who initially worked there. In institutions where the management is careless the data may be misused. Lastly, a weak security system exposes the data to internet virus that might destroy all the files.

Evidence based practice and support

Evidence based practices are professional practices that must be supported by consistent, strong and sufficient research and practical evidence for them to be accepted by boards governing the specific profession like medicine. During the collection of data in hospitals, the medical personnel should record the information with utmost accuracy to improve its credibility for use as evidence during research. Observation of these critical steps in collection and recording of the information guarantees that the information is completely reliable for use in research. Through this the system offers support to the evidence based practices by providing reliable data.

The use of proper, convenient and well detailed methods of collecting and storing data may also be a great effort in the support of evidence based practices. When the medical personnel use methods like note taking, picture taking, questionnaires and where necessary video recording to collect the information about patients, it becomes easier to use the data as the information can directly be used as evidence (French, 2003).

The information recorded as videos and pictures, when analyzed during research can give very accurate and detailed information. This is because; in evidence based practice, the data from video recordings and photos is like a primary source which is more reliable than the other data. The data stored as notes are considered to have probable faults from subjective opinions from a writer thus they are taken as secondary sources.

In medical reports written by the medical personnel from time to time, the trends, frequency and conclusions of specific medical conditions given by the personnel are mainly based on the information from the data base. This reports whose precision is based on the rank of the personnel writing them, are used during the revision of medical rules and procedures concerning the treatment of specific medical conditions (French, 2003).

During a major research activity, before the data analysis and approval has been satisfied, the information findings are critically compared to the medical reports found in the major hospitals before the information can be considered as reliable. In this case, the conclusion is qualified depending on the actual data that is in the field, which is mainly the information in the data base and medical reports of specific diseases from major hospitals. On confirmation of their credibility, the findings are then used as a basis for formulating medical policies, resources allocation in similar institutions, and making other clinical practice guidelines.

In evidence based practices, the more the facts that are directly linked to a reliable source of data the stronger the evidence from the data. The information in the medical field is continuously collected to form a data base which gives the trends. These trends may be used in research activities where it is analyzed through statistical methods. When the information is approved and satisfied to be reliable it can simplify decision making through the development of statistical models, which at this point are considered as proved medical concepts and may be used in any medical field (French, 2003).

Collaboration and Information

Good relations between the employees of any good institutions always helps to improve information sharing and the information collected in the system could be shared in several ways. One of them is through research activity; the information developed during research activities, can randomly benefit all the health care disciplines. For example, a research carried out on the relationship between PTSD and heart diseases; can be used by both the psychological department and the cardiac department in the medical discipline. The integration and use of medication by most patients can be applied by the pharmacy department; to identify the most efficient drugs to be medicated in a specific condition (Saudagaran, 2009).

Secondly, the information may be used in carrying out research activity in any medical field. It may be used in the support of a hypothesis that is related to some other medical condition. Some of the diseases treated in these medical institutions are interrelated. To be able to treat the patient well different medical departments must coordinate through information sharing. This will help in giving the patient satisfaction through a show of concern by the several medical personnel, and good treatment, without one of the diseases being left untreated.

During decision making and resources allocation, the management may have to confirm some information in the data system to approve various projects. For example, in the approval of diversification projects that may not be related with the medical field. Furthermore, some of the information is used by the purchasing and procurement departments to estimate the quantity and quality of material to be purchased. The finance department also requires the information on the consumption of medical supplies to estimate total operating costs of the institution (Saudagaran, 2009).

When the information is shared among the various medical departments the beneficiary will be the patients. Well coordination and sharing of information by staff in the institution ensures excellent services to the patients and the public. Employees will also be able to learn good Interpersonal skills. It is clear that good service delivery builds good will to the firm; this stabilizes the customer base of the institution. In return this is a form of guarantee to the institution of its continuity (Saudagaran, 2009).

References

Burke, W. “Methods Of Evaluating Hospital information systems.” Euromed Journal of Business. 40.5 (2006):30-33. Print.

Dudeck, J. (1995). Hospital Information System. New York: Penguin publishers.

Falletta, V. “Impacts Of Hospital Information Systems On Patients 20.6 (2005): 6-10. Print.

French, G. D. (2003). Evaluating Information Systems In Hospitals. California: New Harbinger Publications.

Saudagaran, S. (2009). Information Management In hospitals. Chicago: Williamson & Sons publishers.

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