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For this assignment you want to reread the scenario presented on the Course Project Introduction page located in Module 01.
After reading the scenario, complete the following:
A=Assessment; utilizing your critical thinking skills, provide an analysis/assessment of what you found
Think about the Electronic Health Record (EHR). Does the problem include technical difficulties with the EHR and the interface for vital signs monitoring?
Think about additional problems that could occur as a result of the error. Does the problem relate to transcription and coding? Could their visit be coded incorrectly leading to billing errors?
R=Recommendation; provide action requested/recommended
Be sure to include details regarding action for the medical administrator.
Include in your plan more training or a change in policy/procedure.
Each section for each part should be a minimum of 3 5 sentences in length and should be free of spelling and grammatical errors. References are not required but if used, must be cited.
You have been in your position as a medical administrator for 6 months. During this time you have noticed a disturbing trend in your facilities Intensive Care Unit (ICU). Errors in documenting patient vital signs are increasing which has led to providers having inaccurate information for care and affecting the patients discharge.
The following is an example of a 35 year old male in the ICU due to fungal pneumonia complicated by COPD. Patient also was in a car accident 2 weeks ago (cause of accident TBD).
T: 98.7 F
You have noticed that the trend in documentation mistakes are always on the respirations (R) and pulse (P). The documentation mistake happened on all shifts and on all computers in the ICU.