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As you start to conduct research on the implementation of a new electronic health record (EHR) in your organization, you know that you have to consider the importance of controlled medical vocabulary (CMV). You know that without a CMV in place, the EHR may be impossible to establish. Discuss the following:
Explain how CMVs are key to effective information operability and achieving modern health care goals.
Discuss some of the complexities that may be involved to create and maintain a CMV.
In this Electronic Health Record (EHR), review the data to learn about the patient and his abdominal pain. Pay particular attention to the last nurses’ note when mother pulled the emergency call light and the MAR.
Utilize Xavier Malton’s case and create your own problem-based plan of care in this EHR that includes:
• identify an ACTUAL priority problem; not necessary to use NANDA nursing diagnosis wording
• type of problem identified
• disease process or etiology contributing to identified problem
• subjective and/or objective data specific to problem, as documented in EHR
• at least one goal using SMART language (specific, measurable, attainable, realistic & timely)
• nursing independent and /or collaborative interventions appropriate to reach the chosen goal/outcome. interventions. See rubric and include at least:
o an assessment intervention
o a physical intervention that you would do
o a patient education or teaching intervention
• supportive rationale for choosing each nursing intervention
Why the EHR is called Longitudinal Health Record or Womb to Tomb health record?