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Clinical Documentation

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Submitted By rbru74
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Clinical Documentation System
Excelsior College October 6, 2013

Clinical Documentation System

Clinical information system (CIS) collects patient data in real time, stores healthcare data and information using secure access to the healthcare team. (McGonigle & Garver Mastrian, 2012, p. 554). The CIS that is used at Texas Health Dallas is CareConnect. CareConnect is used by all of the Texas Health Resources (THR) encompassing 25 hospitals, affiliated physician offices, and ancillary facilities. CareConnect allows physicians and management to access the system on their mobile devices and home computer for real time data. The shift for CIS is set for implementation throughout the United States by 2015. The clients served are those in the community that THR provides healthcare services to. The electronic health record is shared amongst the healthcare team and other affiliates.
Data collection can be continuously updated, used for “statistical evaluation for purposes of quality improvement, outcome reporting, resource management, and public health surveillance.”(Yamada, 2008, p. 5). Data collection is generally initiated in the ER, and other times when the patient is at the physician's office or in the outpatient service line. To reference inpatient services, data collection begins in the ER. The patient's allergies, current medications, medical history, vital signs, immunizations, suicide screening and domestic violence screening are all obtained upon the patient's arrival to the ER. The gathering of this information, initiates a process for interdisciplinary data collection. All healthcare team members can access a patient’s previous visits whether it is outpatient, inpatient, diagnostic or office visit. Labs and radiological tests are shown by date and time and are listed in chronological order. The clinical staff member

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