Electronic Assessment of Patients

I have had considerable use of an electronic medical records system at our large health care facility. In my position as a Chronic Care Coordinator, I outreach patients that have been transtioned home from either a Hospital or from a Skilled Nursing Rehabilitation. One of the main goals we have set in our mission is to decrease readmissions to the hospital. The high re-admission diagnosis are COPD, CHF, Pneumonia and MI. But we also outreach to patients with medical cormobidites. Our tool of choice is an electronic charting system. Every patient’s chart has their personal information, their Demographics, Social Security, Marital status, Emergency contact information, Medical, their Advance Directives:  Living will, Power of Attorney, Cor status, along with HIPPA information. The entire care team has access to any and all information from tests, medications, referrals and care received in any of the contracted hospital in the city region. I interact with patients over the phone and update their electronic chart. Our inital call ocurrs 24- 48 hours after they are home. The charting is in a Subjective, Objective, Assessment and Plan format.  We obtain patient information through questions and outcomes of concerns the patient may have. Through years of experience we have learned to pick up sutle intonations  of patient response to our questions. Many of our questions are open ended and learning from the patients what their understanding is of why they went to the hospial. The patients give us data points such as weight, blood sugar and pulse ox; they tell us how their systems of their bodies have changed. Our objective is to help them live longer or feel better.Healthcare Online Education ConsultantFor Healthful Links and more information, click here.

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