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Medical Information System and Its Issues
A health information system is a software data files, retrieval, and analysis method. It is intended for use with a period, online central processing unit CPU for the quick and easy production, management, and evaluation of generic data files.
It is widely characterized as a system that combines data collecting, processing, reporting, and knowledge usage in order to improve health service efficacy and efficiency via improved management at every level of health care.
Personal healthcare professionals and carers must have access to nearly four different types of health records in order to successfully diagnose and treat patients: the persons medical history, the fast-changing healthcare base, and vendor orders trying to guide the patient healthcare system.
Information management may help with cost control, increasing the speed and accuracy of patient safety and administrative data, increasing service capacity, lowering labor costs and stock levels, and improving the quality of patient care.
Issues with the existing system
Since this system was created for fast processing and compiling data, doctors cannot process these 15-20 percent of the text since the site does not mean tags for them by which this data can be quickly found.
This leads to the fact that the efficiency of searching for the necessary information decreases.
Free text is widely used to keep records of and document the care of individuals, as well as to communicate amongst healthcare practitioners. As a result, unorganized EHR language may give detailed explanations that would be impossible to extract from structured information.
Since the system does not have a standardized language for managing and searching, doctors cannot clearly know on what basis to ask a request on the site because the tagging system works at a poor level, and all search names were invented by developers who are not always competent in matters of the essence of the information in the field of medicine.
This leads to a decrease in the efficiency of the system and frequent misunderstandings in work between employees.
A standard language is a language variation that has had significant grammatical and uses codification. At the same time, the phrase is also used to refer to the totality of a language that contains a standard format as one of its variations.
A Data Dictionary is a collection of titles, classifications, and properties for data components utilized or collected in a database, information system, or research work.
Work-around for using the existing system
To avoid possible problems of information search, it is possible to add the necessary tags for search already in the existing system, albeit with an incorrectly built language.
This will help employees quickly find the information they need or add something to the right section, which was previously more difficult to access.
A tag is a keyword or phrase applied to a piece of information in computer systems. This type of information aids in the description of an object and enables it to be retrieved again through reading or search.
These tags are required to fulfil the need of keeping record validation and encourage the insurance carrier and the police department, in tracking the stolen assets. Tags are also used to:
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Retrieve stolen or lost equipment.
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Keep proper asset records.
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Keep a visual record for lease contracts and other arrangements.
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Required by the insurance carrier for record and validation.
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Required by police to track stolen or misplaced assets.
Since the developers did not take into account possible misunderstandings in their search system, people can contact them so that they revise it and, together with the staff of the medical institution, correct all the necessary tags to simplify the search.
Nursing Language
The use of a standardized nursing language for nursing care reporting is critical for both the nursing practice and the care coordination nurse.
Professional nurses must understand why it is critical to document care utilizing nursing theory languages, notably as more companies transition to electronic documentation (ED) and the usage of healthcare data.
A standardized nursing language should be created in order for nurses and other health care workers to communicate nursing care properly (Johnson et al., 2018).
A phrase may be measured and coded once it has been defined.
The assessment of nursing care in an ED using standardized terminology will result in the creation of enormous datasets.
From these datasets, scientific proof criteria for validating nurses contributions to patient outcomes may be constructed.
The usage of standardized nursing languages provides several benefits to direct bedside nurses.
Improved communication among nurses and other medical companies, provided a glimpse of therapeutic interventions, improved the quality of care, improved data collection to evaluate skilled nursing outcomes, more remarkable ability to adhere to levels of care, and helped facilitate the evaluation of nurses knowledge are some of these benefits.
These benefits for the direct care physician are addressed more below.
A primary benefit of employing a nursing model is better communication with other nurses, health care providers, and managers of the facilities where nurses work.
The use of nurse languages has the potential to improve nursing care communication both domestically and globally.
This is significant because it will alert clinicians to potentially beneficial therapies that are not already in use in their communities.
Nurses job is unknown because they utilize informal notes to orally report to one another instead of patient data and care plans.
Therefore, standardized nursing language has several advantages for the healthcare system. Among them are improved communication between nurses and other healthcare professionals, increased awareness of nursing interventions, and improved patient care. In addition, there is an improvement in data collection for evaluating care outcomes, strict compliance with standards and facilitating the assessment of the competence of medical professionals.
Multidisciplinary Language
Multidisciplinary language is essentially a shared language, nomenclature, categorization, or taxonomy among users.
The use of standardized terminology in health care settings is critical for clearly and correctly documenting client assessments, services, and results.
There are several advantages to utilizing standardized multidisciplinary language, including:
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Achieving interoperable set of criteria;
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Improved coordination and communication;
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Enhancing healthcare coverage on a national and global level by collecting sharable data;
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Adherence to levels of care and practice guidelines;
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Measuring outcomes to assess the efficacy of community health care;
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Increasing the awareness of the work.
Survey Questions
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What are the main weaknesses you can identify in the current system?
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How do you deal with these problems?
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What innovations would you like to bring to the existing system?
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Based on the existing system, what corrections and comments would you suggest to the developers of the new system?
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Are you ready to switch to the new system now and learn how to use it again?
These questions will help to clearly define the attitude towards the existing system and build a general mood for the introduction of the new system. All problems and wishes from employees will also be identified.
Reference
Johnson, L., Edward, K. L., & Giandinoto, J. A. (2018). A systematic literature review of accuracy in nursing care plans and using standardised nursing language. Collegian, 25(3), 355-361. Web.
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