Describe the clinical documentation system including its intended use and function.As a nurse leader assess how a clinical documentation system functions in your workplace setting.

CLINICAL DOCUMENTATION SYSTEM

clinical documentation system

As a nurse leader assess how a clinical documentation system functions in your workplace setting. ( The workplace setting is in a hospital on a labor and delivery unit)
The paper is on the topic of ……As a nurse leader, you have been asked to assess how a clinical documentation system functions in your nursing workplace setting. For this written assignment, address each of the elements noted below. This assignment is limited to 6-8 pages (excluding the title page, abstract and references), must be in the form of a scholarly paper, and reflects APA format.
This scholarly paper addresses the elements noted below:
1. System and Setting Description
1. Describe the clinical documentation system including its intended use and function
2. Describe the type of the setting the system is used in and the clients served.
2. Data Collection and System Analysis
1. Describe how and when is the data collected?
2. Identify who uses the data and how is it retrieved?
3. Analyze if the system functions as intended?
4. Analyze if the system supports the work of the clinicians (workflow)?
3. Safety and Outcomes Analysis
1. Describe how the system supports patient safety and safe care environments.
2. Analyze the impact the system has on improving client outcomes.
3. Discuss the strengths and limitations the system has on supporting clinical decision making and promoting
quality outcomes.
4. Evidence-Based Practice
1. Explain how the data collected from this system can support and serve as the basis for the development of Evidence Based Practice standards of care and clinical practice guidelines.
5. Collaboration and Information
1. Describe how the information generated by the system is or could be shared across healthcare disciplines.
2. Explain how the multidisciplinary exchange of information promotes collaboration and continuity of care.
6. Scholarly Paper.
Reference:
American Nurses Association (ANA). (2008). Nursing informatics: scope & standards of practice.
Springfield, MD: Nursesbooks.org
Mc Gonigle, D., Mastrian, K .G. (2012). Nursing Informatics and the Foundation of Knowledge. 2nd Ed,
Burlington, MA: Jones & Bartlett Learning.
TIGER Informatics Competencies Collaborative (2007) Wiki. Accessed on November 20, 2009 at
http://tigercompetencies.pbwiki.com


 

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