Crystal J. Evans Neehr Perfect Activity
Neehr Perfect Activity: Reporting in the EHR
The assignment required signing into the medical record using my credentials, selecting the specified information from the in-hospital stay, discharge summary and Ashco Health summary. After the specific items were selected, I constructed the graphs for blood pressure, pulse, respiration and temperature using the reports tab. From this activity, I learned how to accomplish these tasks and discover when graphs might be useful. For example, changes in blood pressure, vital signs or lab results over time could suggest further inquiry, vigilance or testing.
Neehr Perfect Activity: Registering a Patient andAdding Orders Part I
The registering a patient and adding orders activities served as an interactive exercise. It introduced me to the steps and procedures required for entering data into a patient’s health record in an accurate, unbiased, and timely manner and did so in ways that facilitated later data extraction. While I did not really learn anything new, I gained more familiarity with the layout of EHR, with the data field arrangement. I also discovered how to view information to be entered, how to cultivate my own mind to perform the tasks accurately and do so with more competence. Additionally, The free text order entry field allows more flexibility when entering exactly what the MD orders. Yet, as the lesson states, this free text entry and MD orders does not necessarily guarantee the orders are free of mistakes.
Neehr Perfect Activity: Cause and Effect
This activity not only highlighted how healthcare roles have changed but also showed how the hectic nature of the tasks performed can lead to interruptions, hurried entries and errors in the EHR. While it is possible to correct these records, the nature of EHR and the ways providers and authorized persons can log onto the records can lead to instances such as medication changes right before the medication should be given. In these cases, it is possible for errors to occur because nurses are not immediately alerted when these changes occur. Nevertheless, this embodies an error, one that is not easily averted or prevented without conversation. It elucidates one of the errors that can arise from use of the EHR. Therefore, identifying the errors in the charts in this activity helped me learn firsthand how and why errors can occur, how information might be mismatched. Overall, it also showed me why I needed to look at the record opened very carefully and consider how and why some information might not match the patient diagnosis and associative standards of care.
Neehr Perfect Activity: Release of Information
By reviewing the patient record, release of information and the components of that release, I was able to apply my knowledge of HIPAA, privacy, and release of information. To identify errors the release contained, I demonstrated understanding of identified terminology and its meaning. After all, the matching exercise also necessitated this knowledge. Nevertheless, small details, such as dates and electronic signatures can be very problematic. This is especially true when the patient is consenting to specific parties for release of information.
Neehr Perfect Activity: Case Study Review
This interactive patient record activity required locating specific information in the EHR, auditing tasks such as reviewing the diagnosis, procedures, prescriptions and methods of drug administration. It also necessitated record review including progress notes, clinical findings and discharge status. In other words, this case study review used all the skills and knowledge I have gained through coursework and learning activities to date. After all, I had to recognize the data and assess the clinical case to determine its congruence with the diagnosis. For these reasons, it was an excellent exercise to apply knowledge and skills and gain competence.