Creating a Standardized Electronic Process to Meet core Measure Compliance in Review Education of Sepsis

Sepsis
Name:
Institution:
Course:
Date:
Current Situation
The fact that there is need to maintain accurate medical records in some of the cases drives medical professional to follow the documentation protocols more than they rely on the medical research. This is relative to the fact that whatever procedure they take into is going to largely affect the element of documentation. Ideally due to the fact that most of the medical professions require that there are accurate medical records, there is an element of the records overrunning the need to follow modern research practices ("What is medical auditing?", 2016). In other cases, medical professionals will be forced to use the practices that are easily documented and ones that allow for ease of recording.
It is important to note that medical records are a crucial part of the health care systems. This is relative to the fact that the records play a vital role in the diagnosis of the health conditions of a patient in latter procedures. This means that, when there are accurate medical records on a patient relative to past medical conditions and treatment plans along with other medical interventions carried out, the current condition can easily be identified and dealt with in an accurate manner. This further comes in handy as part of good medical practices ("What is medical auditing?", 2016). It is also important to note that the element of keeping accurate medical records comes in handy relative evidence of care. This is to mean that, the records are a basis for evidential background. Any other medical professional or even the patient can easily follow up on the various medical interventions that were used and the various reactions that the body brought about. It is also the official method of communication. When a nurse put on record whatever interventions that that were administered on a patient, this is a means of communicating with the rest of the medical professionals. Ideally, any other medical professional that is going to interact with the patient at the hospital or another hospital will have access to the previous medical records that pertains to the patient ("What is medical auditing?", 2016). It is through this form of communication that medical teams are able to bring about proper diagnosis on a patient.
Historical relevance
The medical records systems are largely referred to as health information systems. And their history can be traced back to the 1920s (Brooks, 2016). This was at a time when medical professionals realized the benefits of keeping medical records relative to them and the patients. At this time the medical professional had realized that they were able to treat the patient with accurate medical records which further helped with diagnosis. Later on the element of safety came to the health care sector and more emphasis was placed on quality of care. To standardize the records that were kept by the different health care professionals and facilities, an organization was established namely the American association of record librarians of professional association. Later the organization was rebranded to American health information management association (Brooks, 2016). At the time most of the records were done on paper which explains the medical records that to date manually entered on filed paper forms.
The 60s and the 70s brought on a different revolution, with the advent of technology. The development of computers encouraged the introduction of information systems which became quite common in most of the institutions at the time. With quite a number of universities going n research about how best the computer systems could be used to the benefit of the institutions and by extension in the economy, the information age was brought on board (Brooks, 2016). Early in the development stages, the medical records would be generated at the point of entry. This means that much of the information that was recorded on any given patient would be accessible only at the facility where the patient data was collected. This thus had some element of limitation to the effectiveness of the software outside the facilities. As such, the patient and the medical professionals would only benefit from the records at the point of generation. There was also the element of the computers having limited processing power. At the same time, due to the fact that they were quite few and cost a lot of money to develop, they were also quite expensive to purchase, setup and operate at the time. This thus mean that most of the hospitals did not have the resources to run computerized medical records; as such they continued with the use of the manual system. With the advent of the internet, the medical information systems have been revolutionized to embrace interconnectivity. As such the medical records can now be accessed from different parts of the hospital and even outside the facility by other medical professionals provided they have the clearance for the same ("History of medical record-keeping", 2016).
Over the years, due to the fact that the medical records have been trusted for accuracy for quite some time, the overreliance has largely turned into a hindrance of quality care (Zozus, 2016). The element of relying on medical records has developed into an barrier to quality care relative to the fact that, most of the medical professional now rely heavily on the records other than the medical research that exists.
‘Meredith Nahm Zozus, assistant professor of Biostatistics and Bioinformatics at Duke, has received nearly $1.4 million for a research project to expand involvement of patients in determining the accuracy of medical data used in research. "Measuring data quality requires a source of truth or a gold standard – something to which the data in question can be compared," Zozus says. "In health care, patients are beginning to be tapped as this source for comparison." It is commonplace, for example, to ask patients to self-report on medication use during office visits and use that data to update the electronic health record. Zozus believes that patients can improve the quality of research data in a similar way. The funding for this study…The study will compare self-reported data and electronic health record data to identify discrepancies. After identifying discrepancies, the researchers will interview patients to identify the cause of the discrepancy and determine which data source is accurate. Afterwards, the study will examine the proportion of discrepancies that patients report to health systems and the likelihood that a reported discrepancy results in an actual change in the health record. Ultimately, the researchers want to know whether the changes affect guideline-based clinical decision-making.’ (Zozus, 2016)
This means that, while there may be a different and reliable medical intervention, medical professionals are likely to use the medical records to determine the ones to use other than rely on newer and effective treatment plans. There is a significant indication that there are some discrepancies that exist between the medical records and the self-reported medical conditions from the patients. However, due to the fact that medical professional have the culture of relying heavily on the medical records, they tend to overlook the fact that, these discrepancies exist and there is need to work with the patients. It is for this reason that medical records need to be established relative to the accuracy ascertained by the patients.
Sepsis
This is one of the most dangerous health complications and one that relates to infections. Ideally, it is related to life threatening complications that are caused by infections. Sepsis takes place when the chemicals released into the blood to fight the infection end up triggering inflammation (Sarsfield, Wengert & West, 2016). Due to the changes that take place in the body at the tissue level, this can lead to tissue damage, organ failure and in the extreme cases it may lead to death of the patient. Patients will show signs of increased fever where the body temperature is above 38 degrees Celsius, elevated heart beats above 90 beats per minute, elevated breathing rate above 20 breaths per minute. In some of the cases, the sepsis can degenerate into severe sepsis, where the patient is likely to show signs of significant reduction in urine production, experience difficulty breathing, confusion, abnormal heart beats, a decrease in the number of platelets and in some of the cases the patient will complain of abnormal pains. As it degenerates further, the patient goes into septic shock, where they will show any of the aforementioned signs and symptoms and extremely low blood pressure that will not normally respond to simple fluid replacement (Sarsfield, Wengert & West, 2016). This condition is mostly common among patients that are already hospitalized especially where the patient has undergone some element of surgery (Mack, 2015). Any type of infection ranging from viral, bacterial and fungal can lead to sepsis however the most common varieties include; kidney infection, infection of the blood stream, pneumonia and in some of the cases abdominal infection.
There is need for the medical records to allow for the patients involvement in the refinement of the medical histories to avoid the major discrepancies. It is common practice among the medical practitioners to use the medical records to treat patients relative to the medical records that they can find. Relative to the level of reliance on the medical records there is a likelihood that if there are discrepancies, the patient can be misdiagnosed (Mack, 2015). In the case of complications, it is very easy for the medical practitioners to misdiagnose and find it very hard afterwards to help the patient recover. In the case of the sepsis infections, chances of a misdiagnosis are quite high as they are largely not related to any other diseases or conditions that the patient has had in the past.
In most of the cases, the sepsis infections take place in the hospital setting. This means that the infection is almost never related to the disease or the condition that the patient is battling. One of the most common infection is the bloodstream infection that is associated with central lines (Sarsfield, Wengert & West, 2016). In such a case as the one where the patient is infected at the hospital relative to an incidence where the nurse did not use sterilized equipment or hands when han...