NURS FPX 6612 Assessment 3 Patient Discharge Care Planning.pdf

Assessment 3: Patient Discharge Care Planning
Student Name
Capella University
Course Name
Prof Name
June 24, 2023
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Patient Discharge Care Planning
Introduction:
This assessment focuses on developing a comprehensive discharge care plan for Marta
Rodriguez following her recent hospitalization due to a severe accident en route to college. With
a four-week stay in the trauma center, multiple surgeries, and antibiotic treatments, coordinating
Marta's care post-discharge is crucial. As the senior care coordinator, my role is to present
Marta's case at an upcoming interdisciplinary team meeting to formulate effective discharge
plans.
Holistic, Patient-Focused Care Plan:
Ensuring Marta Rodriguez receives comprehensive, patient-centered care involves integrating
Health Information Technology (HIT) components. These tools include electronic health records
(EHRs), secure messaging platforms, telehealth technology, and medication reconciliation tools.
EHRs will enable real-time access and updates to Marta's medical records, supporting the
development of a thorough care plan (Schwab et al., 2021).
Secure messaging platforms will streamline communication among team members, facilitating
updates on Marta's condition, appointments, and medication schedules (Flickinger et al., 2022).
Telehealth technology allows for remote monitoring of Marta's vital signs, enabling early
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intervention as needed (Chowdhury et al., 2020). Additionally, medication reconciliation tools
ensure accuracy in her medication list, minimizing the risk of errors.
To mitigate the risk of Marta's readmission within 48 hours post-discharge, the interdisciplinary
team must prioritize patient education, support, and follow-up care (Oksholm et al., 2023).
Leveraging HIT components can strengthen these efforts. For example, telehealth technology
can monitor Marta's progress, offer virtual support, and identify potential issues early on. Secure
messaging platforms will provide Marta with timely information regarding medications and
follow-up appointments.
Integrating HIT components enhances care coordination for Marta by fostering communication
and collaboration among team members. Access to consistent information about Marta's health
status facilitates the creation of a comprehensive care plan. EHRs enable continuous tracking of
Marta's progress, ensuring she receives appropriate care throughout her recovery. By
leveraging HIT effectively, the interdisciplinary team can deliver a tailored, coordinated care plan
that meets Marta's individual needs.
Data Reporting:
Data reporting is pivotal in healthcare, influencing care coordination, administrative decisions,
clinical efficiency, and interdisciplinary innovation in treatment. In Marta Rodriguez's case, data
reporting enhances her care quality and supports her recovery in several ways:
1. Care Coordination: Data reporting facilitates interdisciplinary collaboration by providing a
shared understanding of Marta's condition and progress (Brooks et al., 2020). Reporting data on
Marta's medication adherence, vital signs, and symptoms through EHRs or secure messaging
platforms enables effective care management, reducing complications and readmissions.
2. Care Management: Data reporting informs care management by identifying areas where
Marta may need additional support or interventions. Information on pain levels, mobility, and
nutritional status informs adjustments to her care plan, enhancing its quality and promoting her
recovery.
3. Interdisciplinary Innovation: Data reporting drives innovation in interdisciplinary care by
offering insights into Marta's behaviors and preferences. Information on her cultural background
or language preferences helps tailor care, promoting patient-centered approaches and
improving outcomes.
To ensure data quality, protocols for data validation, regular audits, and training in data entry
and reporting best practices are essential. Data relevance to Marta's care goals and adherence
to evidence-based practices empower the team to make informed decisions, delivering optimal
care.
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Impact of Client Records on Health Outcomes:
Patient records play a critical role in improving health outcomes by enabling interdisciplinary
teams to collect, analyze, and share crucial information. Marta Rodriguez's case illustrates how
HIT supports these efforts, enhancing patient care and outcomes. Here’s how:
HIT empowers interdisciplinary teams to gather and analyze data from client records, identifying
trends, patterns, and care gaps (Leslie & Paradis, 2018). Marta's records provide vital insights
into her medical history, medications, and health status, guiding the development of a
personalized care plan that addresses her unique needs. HIT also identifies risks such as
adverse reactions or complications promptly, enabling timely interventions to prevent negative
outcomes.
Moreover, HIT fosters care coordination among team members by facilitating real-time
information sharing. EHRs and secure messaging platforms ensure all team members have
access to updated patient information, minimizing errors and enhancing communication. This
collaborative approach ensures holistic care that addresses all aspects of Marta's health,
ultimately leading to improved health outcomes.
Conclusion:
Marta Rodriguez's discharge care plan emphasizes a patient-centered approach with effective
care coordination. Leveraging HIT components—EHRs, telehealth technology, secure
messaging platforms, and medication reconciliation tools—enhances communication and
collaboration across her care continuum. Data reporting plays a crucial role in improving care
coordination, clinical efficiency, and interdisciplinary innovation, providing valuable insights into
Marta's behaviors and preferences. Client records serve as essential sources of data for
optimizing health outcomes, enabling interdisciplinary teams to collect, analyze, and share
information effectively. By utilizing HIT effectively, the interdisciplinary team ensures Marta
receives comprehensive support, education, and follow-up care, reducing the risk of
readmission within 48 hours post-discharge.
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References
Brooks, E. M., Winship, J. M., & Kuzel, A. J. (2020). A “Behind-the-Scenes” look at
inter-professional care coordination: How person-centered care in safety-net health system
complex care clinics produces better outcomes. International Journal of Integrated Care, 20(2).
https://doi.org/10.5334/ijic.4734
Chowdhury, D., Hope, K
. D., Arthur, L. C., Weinberger, S. M., Ronai, C., Johnson, J. N., & Snyder, C. S. (2020).
Telehealth for pediatric cardiology practitioners in the time of COVID-19. Pediatric Cardiology,
41(6), 1081–1091. https://doi.org/10.1007/s00246-020-02411-1
Flickinger, T. E., Waselewski, M., Tabackman, A., Huynh, J., Hodges, J., Otero, K., Schorling,
K., Ingersoll, K., Tiouririne, N. A.-D., & Dillingham, R. (2022). Communication between patients,
peers, and care providers through a mobile health intervention supporting medication-assisted
treatment for opioid use disorder. Patient Education and Counseling.
https://doi.org/10.1016/j.pec.2022.02.014
Leslie, M., & Paradis, E. (2018). Is health information technology improving inter-professional
care team communications? An ethnographic study in critical care. Journal of Interprofessional
Education & Practice, 10, 1–5. https://doi.org/10.1016/j.xjep.2017.10.002
Oksholm, T., Gissum, K. R., Hunskår, I., Augestad, M. T., Kyte, K., Stensletten, K., Drageset, S.,
Aarstad, A. K. H., & Ellingsen, S. (2023). The effect of transitions intervention to ensure patient
safety and satisfaction when transferred from hospital to home health care—A systematic
review. Journal of Advanced Nursing. https://doi.org/10.1111/jan.15579
Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P.,
Peytremann-Bridevaux, I., & Gilles, I. (2021). An overview of reviews on inter-professional
collaboration in primary care: Barriers and facilitators. International Journal of Integrated Care,
21(2), 32. https://doi.org/10.5334/ijic.5589
Schwab, P., Mehrjou, A., Parbhoo, S., Celi, L. A., Hetzel, J., Hofer, M., Schölkopf, B., & Bauer,
S. (2021). Real-time prediction of COVID-19-related mortality using electronic health records.
Nature Communications, 12(1). https://doi.org/10.1038/s41467-020-20816-7
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NURS FPX 6612 Assessment 3 Patient Discharge Care Planning.pdf

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