Electronic health Records (HER) Case study

Electronic health Records (HER) Case study

Type of document       Case Study      Number of pages/words          3 Pages Double Spaced (approx 275 words per page)

Subject area       Nursing          Academic Level            Master

Style    APA     Number of sources/references            1

Order description:

1. Provide a summary of the case
2. Describe: who the members of each team are and how their actions contributed to patient outcomes.
3. Explain how informational systems and information in Mr. Head Injury’s EHR were used to diagnosis and treat Mr. Headache.
4. List what knowledge team members needed to effectively use the data and the EHR
5. Discuss what meaningful use metrics were used in the care of this patient.
6. Create a diagram of how the workflow currently exists (termed ‘As Is’) to represent the scenario with Mr. Head Injury. Create a separate diagram of how this workflow might be improved (termed ‘To Be’) using information technology and the EHR. What meaningful use metrics will be met in the ‘To Be’ diagram? Provide a brief narrative of how the workflow could be improved as demonstrated by the ‘To Be’ diagram.
7. Describe how an interprofesional team approach along with the EHR improvements could have improved Mr. Head Injury’s care and how these changes will improve care overall for the patient population at this facility.

Mr. Head Injury, a 75 year old male presented to the ER with a chief complaint of ground level fall with closed head injury. He arrived alone from an assisted living facility without family. Family lives in a different state and the patient is alert and oriented, but a poor historian. When asked about his medical history, the patient reported,

“I have high blood pressure. The doctor says I need to cut back on my fatty foods, something about my blood levels being too high or too low. I had a heart attack last fall, and I have pain in my joints. I’s not too good on my feet any more, I have to use a cane to get around now a days. That’s why I’m living over at Summerdale so I can have help around the house. I fell down on my way to afternoon tea. I don’t know if I tripped or what. There might be something else, I think…but I guess that’s about it.”

When asked for a family member’s contact information, the patient reports “Everyone I know is using a cell phone these days so, I couldn’t tell you any one’s telephone number.” For medication history, the patient reported, “Well, I take 2 pills for blood pressure one in the morning and two at night, a baby asprin, those little white pills that go under my tongue when my chest hurts. There is something else I’m on, some new medication, but i can’t remember and I’m not even sure what it’s for… I’m not one to create a fuss. I just take the pills when the doctor tells me to. I was here not long ago. I bet you already have a list of my medications.”

Per patient, a medical history is compiled: Hypertension, Hypercholesterolemia, Coronary Artery Disease, history of MI within the last six months, and arthritis.

Medication List automatically compiled in the EHR from the last visit reveals:

• Lisinopril 20mg by mouth daily
• Lopressor 50mg by mouth twice daily
• Simvastatin 40mg by mouth daily
• Asprin 81mg chewable by mouth daily
• Nitro sublingual 0.4mg every five minutes as needed times 3

Upon further review of discharge data from this previous admission, it is found that the patient was given a prescription for Digoxin 0.5mg by mouth daily and instructions to follow up with his cardiologist in three days after discharge.

In the EHR of a follow up office visit with his cardiologist two months ago, it was noted that the patient was started on Coumadin 2mg by mouth.

During his previous admission, the patient had given demographic information and an emergency contact which was compiled on a face sheet and available in the EHR and had a previous living will and power of attorney on file that had been scanned in by medical records and filed within the system for easy access.

The nurse calls the emergency contact on file and is connected with the patient’s daughter who lives in another state but knows the patient’s medical history and will obtain a detailed list of medications from her father’s local Pharmacy if needed.

The EHR utilizes Surescript solutions in which the patient’s prescriptions are automatically compiled in the record after they are prescribed and filled at the patient’s local pharmacy. The current list revealed the following medications.

• Lisinopril 20mg by mouth daily
• Lopressor 50mg by mouth twice daily
• Simvastatin 40mg by mouth daily
• Asprin 81mg chewable by mouth daily
• Nitro sublingual 0.4mg every five minutes as needed times 3
• Coumadin 2 mg by mouth daily
• Digoxin 0.5mg by mouth daily

The Physical assessment revealed the patient had no neurological deficits and only slight tenderness and hematoma to the right parietal scalp.

Clinical diagnostic tests performed based on patient’s chief complaint, history, and review of EHR included: EKG, CBC, CMP, digitalis level, PT w/ INR, & CT scan of the head without contrast.

Upon evaluation of clinical diagnostic tests, it is revealed that the patient has a subdural hematoma, and INR of 8.0, and the patient’s digitalis level is slightly above therapeutic. The patient was admitted to the Neuro-ICU for observation and treatment.

Due to your expertise in EHR and interprofesional team approaches, your team has been invited by the Quality Officer in the institution to review Mr. Head Injury’s case. You are to determine the main factors that contributed to Mr. Head Injury’s successful diagnosis and treatments. you are asked to make recommendations on what processes to highlight to improve EHR use in the ER to improve meaningful use and enhance safe patient outcomes.

1. Provide a summary of the case
2. Describe: who the members of each team are and how their actions contributed to patient outcomes.
3. Explain how informational systems and information in Mr. Head Injury’s EHR were used to diagnosis and treat Mr. Headache.
4. List what knowledge team members needed to effectively use the data and the EHR
5. Discuss what meaningful use metrics were used in the care of this patient.
6. Create a diagram of how the workflow currently exists (termed ‘As Is’) to represent the scenario with Mr. Head Injury. Create a separate diagram of how this workflow might be improved (termed ‘To Be’) using information technology and the EHR. What meaningful use metrics will be met in the ‘To Be’ diagram? Provide a brief narrative of how the workflow could be improved as demonstrated by the ‘To Be’ diagram.
7. Describe how an interprofesional team approach along with the EHR improvements could have improved Mr. Head Injury’s care and how these changes will improve care overall for the patient population at this facility.