Identify what data element should included in ehr assessment


Assignment: Evidence-Based Practice Case Study

You are consulting with the education and practice development team in a large tertiary care hospital serving a region comprising mostly rural communities. The team is responsible for strengthening the implementation of EBP based on outcomes. Over the next 2 years, it must set performance objectives to (A) strengthen screening for pain, depression, and adverse health behaviors (smoking, excess alcohol intake, and body mass index [BMI] greater than 30) at intake for all adult admissions; (B) implement comprehensive geriatric assessment for all those over age 65 hospitalized for more than 7 days or readmitted within less than 3 days following discharge; and (C) promote care-team performance.

The hospital has 200 adult admissions each week and has implemented an electronic health record. Guideline dissemination generally occurs through educational venues or via the electronic policy and procedure manual. The method of documentation for narrative notes is documentation by exception using subjective, objective, assessment, and plan (SOAP) and the hospital has made extensive use of checklists to complement the documentation system.

Discussion Questions

I. (200 words) Using clinical guidelines and standards of care, identify what data elements should be included in the EHR assessment and evaluation screens if these goals are to be achieved.

II. (200 words) Identify how information system defaults and alerts could be used to achieve these goals.

III. (200 words) Once screening has been improved, what are the next steps in improving patient outcomes?

IV. (200 words) How could the electronic health record be designed to support these outcome-related goals?

Format your assignment according to the give formatting requirements:

1. The answer must be double spaced, typed, using Times New Roman font (size 12), with one-inch margins on all sides.

2. The response also includes a cover page containing the title of the assignment, the course title, the student's name, and the date. The cover page is not included in the required page length.

3. Also include a reference page. The references and Citations should follow APA format. The reference page is not included in the required page length.

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