In my personal nursing practice one of the important areas regarding data collection is the collection of patient data before their admission. I work in adolescent psychiatric and behavioral health, so it is extremely important to have a level of background information on my patients before they arrive to our facility. I must first ensure that the new patient will meet our admission criteria. I can then begin the knowledge acquisition process to learn as much as I can about the patient coming my way.
The data that I collect prior to admission is often based on the patient’s electronic medical record within the computer system. The information that I collect would include their primary and secondary diagnoses, prior assessments, hospitalizations, past treatments, lab results, and medications used. Stoots (2015) shared that psychiatric XXXXXX XXX are actively XXXXXXX in XXX XXXXXXXXXXXX XX XXX XXX to support XXXXXXXXXX XXXXXX XXXXXXXXXX XXXXXXXXXX can XXXXXX to XXXXXXXX XXXXXXXXXXXX in XXXXXXXX outcomes XXXXX XXXX costeffectively directing XXXXXXXXXX XXXXXXX geared XX XXXXXXXXXX XXX XXXXXXXXX of XXXXXX XXXXXX XXXXXXXXX XXX the myriad XX co-XXXXXXXXX XXXXXX conditions. It XX XXXXXXXXX XX see XXXX has XXXX XXXX in XXX past to XXXXXXX a new and updated plan XX XXXX for XXX XXXXXXX. Knowing what XXX XXXXXX or failed is XXXXXXX to developing a XXXXXXXXXX plan XXX achieving positive XXXXXXX outcomes.
XXX XXXXXXXX XXXXXX is now XXXXXXXXX XX with XXXX information and safety alerts XXXX XXXX before, and the technology XXXXXXXXX XX XXXXXX. XXXXX, Sermeus, and XXXXXX (2017) XXXXXX that XXX knowledge will be automatically integrated and embedded into XXXXXXXXXX patient records, and include XXX algorithms for decision XXXXXXX XXXXXXX. XXXXXXXX XXX electronic XXXXXXX XXXXXX is XXX the XXXXXX form XX healthcare XXXXXXXXXX XXXXXXX, it XX constantly XXXXX updated to XXXXXXX the XXXXXXXXXX team XXX XXXXX with XXX most XXXXXXX XXXXXXXXXXX XXX XXX. In XXXXXXXX to XXXXXXXXX the history XX XXXX XXXXXXX XXX XXXXXXXXX XXXXXXXXX XXXXXXXXXXX XX XXXXXXX our care, XX can XXXX XXXXXX XXX then and provide XXXXXXXXXXX XXXXXXXX XX XXX patient XXXX XXX XXXXX of a XXXXX.
The hypothetical XXXXXXXX XXXX I XXXXX XX discuss XXXXXXXX the awareness XX a XXXXXXX’s adverse XXXXXXXXXXX XXXXXXXX XX a medication XXXXXXXXXX during a XXXX XXXXXXXX XXXXXXXXX. XX adverse or undesirable response to a XXXXXXXXXXX medication XXX cause extreme XXXXXXXX to XXX patient while XXXX hindering XXXXX XXXX XXX XXXXXXXX a possible XXXXXX situation. XXXXXXXX patients may XXX XXXXXXX the desired reaction from XXXXXXXXXXX medications, these are XXX XXXXXXXXXXX XXXXXX or flagged as “allergy” in XXX patients record. XX XXX XXX that the XXXXXXX has XXXX XXXXXXXXXX XXXXXX in XXXXX chart, and we XXX not know XXXXXXX why it was discontinued. XXXXXXXX it is imperative to XXXXXXX XXX XXXXX XXXXXXXXXXX XXXX XXX XXXXXXX, XXXX may not remember XXXXXX XXX increased XXXXXXXXX XX they XXXX XXX in the right XXXXX of XXXX at XXX time. In XXXXX the XXXXXXX’s medical XXXXXX, XX can look through XXXX providers and staff XXXXX of those who have XXXXXX with the XXXXXXX in the XXXX. When a XXXXX XX reporting findings to the XXXXXXXX, it XX XXXXXXXXX for XX XX document XXXXX behaviors to XXXXX XXXX XXXXXXXX in the XXXXXX. Reviewing XXX utilizing this XXXXXXXXXXX XX helpful XX achieving a XXXXXX level of care XXX the XXXXXXX.
Knowing that a XXXXXXX has XXXXXXXXXXX a certain reaction XX a medication or XXXX a XXXXXXXXX is extremely XXXXXXX XXXX helping patients XXXXXXXXXX in XXX psychiatric field. If a patient has had XXXXX, XXXXXXXXXX, or self-XXXXXXXXX XXXXXXXXX in response to a XXXXXXXXXX XXXX XXXXXXXXXX, XX would make XXXX XXXX XXX XXXXXXXXXX XXX XXX used XXXXX during XXX care. We XXXXX also flag XXX medical record to alert others of XXX reaction as well if that XXX XXX XXXX XXXXXXX. I have XXXXXXXXX XXXXXXXXX XXXXXXXXXX XXXX this in our XXXXXXXX before, and we were fortunate to XXXX XXXXX XXXXXXXXXXX XX care to XXXX the XXXXXXX. Adolescents are XXXXX XXXXXXXX XX discuss sensitive XXXXXXXXXXX with XXXXXX that they do XXX know. In my personal experiences, it XXX been helpful XX have XXXXXXXXXXX ahead XX XXXX to XXXX a XXXXXX understanding XXXX XXXXX are hesitant XX XXXXXXX. In addition to XXX medical XXXXXX, I also XXXXXX a verbal report XXXX the prior XXXXX XXXX was XXXXXX XXX my XXXXXXX. XXXXXXXX XXX data collected through XXX patient record is XXXXXXXXX XXXXXXX, I XXXX XX verbally hear from XXXXX XXX have XXX direct contact XXXX the patient XX well. Although the XXXXXXX record should XXXXXXX us XXXX a clear XXXXXXX XX XXX XXXXXXX, XXXXX are XXXX things XXXX XXX XX XXXXXXXX through a verbal report. XXX XXXX team XX XXXXX the XXXXX XX realized subtle XXXXXXX in XXX patient, so I XXXX to discuss the patient XXXXXXXXX XXXX the prior XXXX XXXX and then bring that information XX XX own.
XXXXXXXXXXXXX and continued collaboration XXXXX team XXXXXXX is XXXXXXXXX XXX XXXXXXX XXXX XX XXX patient. XXXXXXXXXX, my facility XXXX a computer XXXXXX XXXX XXXXX out XX numerous local hospitals and XXXXXXXXX. In addition to verbal communication among XXX own XXXX XXXX, I can XXXX read XXX XXXXXXXX notes XX my fellow XXXXXXXXX XXX outside XXXXXXXXX that XXXX XXXXX for XX XXXXXXX. Having XXXX important XXXXXXXXXXX XXXXXXXX XX XXX my XXXX with an XXXXXXXXX. With XXX of XXX XXXXXXXXXXX that I XX able to XXXXXXX XXXX the XXXXXX, XXXXXX report, XXX patient, I XXX then XXXXXXX what has XXXX found to XXXXXXX a XXXX XX XXXX forward. McGonigle XXX XXXXXXXX (2017) shared that XXX steps to XXXXX information, XXXXXXXX XXXXXXXXX to a XXXXXXX, and acting with wisdom XXXX XXX basis of XXXXXXX practice science. Knowing where my patient XXXXXX is key to developing a XXXXXXXX XXXXX XXX XXXXXXXX a XXXX XXXX that the patient XXX XXXX XXXX feel comfortable with.
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McGonigle, D., &XXX; XXXXXXXX, K. G. (XXXX).XXXXXXX informatics and XXX foundation XX XXXXXXXXX (XXX ed.). Burlington, XX: Jones & Bartlett Learning
XXXXX, L. M., XXXXXXX, X., & XXXXXX, A. (2017). XXXXXXXX Role XX XXX XXXXXXX Informatics XXXXXXXXXX.XXXXXXX XX XXXXXX Technology And Informatics,232, 212–221. Retrieved from https://XXXXXX.unil.ch/resource/XXXXXX:BIB_4A0FEA56B8CB.P001/XXX.
Stoots, M. (XXXX). Unlocking Electronic Health Record XXXX XXXXX XXXXX XXXXXXXXXX XXXXXX Population Management.XXXXXXX XX XXX XXXXXXXX Psychiatric XXXXXX XXXXXXXXXXX,XX(X), 348–350. doi:XX.1177/1078390315608193
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