Question

You are a health information management professional at Happy Hospital. Since the hospital is moving toward adopting more value-based initiatives, you are tasked with:

Nurse X and Nurse Y are confused about the sections and requirements needed in clinical documentation. They have come to you with the sections listed below. How would you educate and inform them as to what needs to be added or changed regarding what they have done thus far? What the nurses have done thus far is gather the points listed below. The document to be designed is the clinical document itself. All relevant sections should be included in this document.

• Medications
• Physical exams
• Laboratory results
• Diagnoses
• Current immunization record

Answer 1

Being a Health information management professional my task is to provide my best in terms of informatics in the field of healthcare . Utilisation of informatics system the best way in healthcare to provide efficient services to the patients and healthcare staffs.

While inculcating informatics in the Health sector ,there are few important components which needs to taken care of and these are the core and basic components of healthcare :-

Medications

Physical exams

Laboratory results

Diagnoses

Current immunization record

# When we make the software ,there should be separate templates for each components . In the medication template tthere should automatic capture of medicine when we put two or more alphabets , route ,dose , patient name , bed number , cost , etc all should be pre loaded to the system which gets stored when the patient initially gets registered to the system .

In the physical examination template , there must orderwise arrangement of different organ systems and box to be filled by the healthcare professionals

In the laboratory results template there must be provision of observation of report , different laboratories etc

In the diagnosis template the there should be diagnosis pre captured and on putting the two or three alphabets the diagnosis should pop up and also describe left or right anterior or posterior etc

In the immunization record template the whole immunization chart has to be copied down and according to the age child immunization status must pop up automatically and tick mark if the child has got and mark it pending if not recieved and time is left for the immunization .