Electronic clinical documentation is a system used by physicians and nurses to document all the relevant information about the patients admitted to the healthcare institution. Documentation of this information with a clinical decision support system is essential in nursing. CDSS is an integrated system that allows the nurses and the physicians to easily enter the patient’s information and utilize this information to determine diagnosis and treatment modalities to be used. I selected this topic since CDSS is the most utilized healthcare system. I used national healthcare databases for this search, and the main search terms were the clinical decision support system and clinical documentation.
Annotated Bibliography
Mahmoud, A. S., Alkhenizan, A., Shafiq, M., & Alsoghayer, S. (2020). The impact of implementing a clinical decision support system on the quality of healthcare services in a primary care setting. Journal of Family Medicine and Primary Care, 9(12), 6078. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928113/
The main aim of this article was to investigate the impacts of the clinical decision system in enhancing care in primary care settings. The authors postulated that the clinical decision system could impact the quality of patient care in any healthcare facility. The authors of this article conducted a background study in a certain healthcare institution to evaluate the effectiveness of the implemented CDSS system. According to this study, the quality of healthcare and patient safety improves with CDSS usage in various aspects. CDSS increases the uptake of the vaccine among adult patients. The uptake of cancer screening also increases by far with the use of this technology. The diagnoses of different types of cancer also increase with CDS use. In conclusion, using the CDS system in clinical settings enhances care provision by improving various aspects of care, such as diagnosis and treatment. The clinical decision support system is essential in nursing practice. This technology eases the work of the nurses, thus enabling them to evade medical errors caused by poor documentation of patients’ information. CDSS also enhances the work of the interdisciplinary teams since care coordination is made easier by this technology. This article is a good source of information since it enlightens on the impacts of CDS on healthcare quality.
Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and strategies for success. NPJ digital medicine, 3(1), 1-10. https://www.nature.com/articles/s41746-020-0221-y
The main aim of this article was to explain how the clinical decision support system functions and the various strategies that can be implemented in healthcare to enhance its effectiveness. The authors of this article also give an overview of the major systems that comprise the conventional and the contemporary clinical decision system. However, the conventional system is the most common in various healthcare institutions. According to the authors, a clinical decision support system enhances the quality of care and the safety of the patients. The safety of patients is enhanced by eliminating common medical errors in care provision. With CDSS, medical errors such as Drug-drug interaction have been eliminated by integrating the system with various drug and medication administration components. CDSS enhances the quality of care by encouraging clinical management. According to the authors, using CDSS enhances adherence to all the clinical guidelines of care provision, thus enhancing the quality of care. The clinical decision also enhances nursing practice and the work of interdisciplinary teams. This technology increases the efficiency of the nurses by enhancing accuracy in their work. The work of interdisciplinary teams is also enhanced via care transition by CDSS. This article is a relevant source of information since it enlightens on the basics of the clinical decision system and how it has been useful in healthcare.
Musen, M. A., Middleton, B., & Greenes, R. A. (2021). Clinical decision-support systems. In Biomedical informatics (pp. 795-840). Springer, Cham. https://link.springer.com/chapter/10.1007/978-3-030-58721-5_24
This article discusses how the clinical decision support system helps document patients’ information and is used for making informed decisions. The article also discusses how the technology and the current health conditions put a lot of pressure on the CDSS. However, with effective CDSS, the pressure on this system can be evaded, and it can function effectively in documenting and making informed decisions. According to the authors, a clinical decision system is essential in enhancing the safety of the patients and the quality of care. CDS allows healthcare providers to document information required to improve patient care. CDS also provides context-relevant information, preventing mix-ups that can lead to medical errors occurring during care provision. The author also states that the current standard used in deploying the Clinical Decision system is vital in ensuring that accurate information is documented, thus preventing errors. Generally, the latest CDS promotes the patient’s safety while delivering high-quality care. The authors also highlight how the clinical decision system informs the nursing practice and the work of interdisciplinary teams by enhancing the work of the registered nurses and even the nurse assistants. CDS is also efficient in ensuring that the collaboration between various interdisciplinary teams is consistent by containing relevant information for care. This article is relevant in informing the current trends and standards in using CDS and how they impact healthcare quality.
Al-Jaghbeer, M., Dealmeida, D., Bilderback, A., Ambrosino, R., & Kellum, J. A. (2018). Clinical decision support for in-hospital AKI. Journal of the American Society of Nephrology, 29(2), 654-660. https://jasn.asnjournals.org/content/29/2/654?utm_source=TrendMD&utm_medium=cpc&utm_campaign=J_Am_Soc_Nephrol_TrendMD_1
The main aim of this article was to evaluate the impacts of incorporating electronic documentation using CDSS in the care of patients with Acute Kidney Infections. According to this article, acute kidney infections are always associated with high mortality rates. However, these mortality rates are complicated by the lack of efficient CDSS systems for documentation in various healthcare institutions. According to the authors, it is evident how the clinical decision support system enhances the quality of care and safety of patients suffering from AKI. The research conducted by the authors indicated that the incorporation of a clinical decision support system in the management of AKI reduces the rates of mortality. This is because the electronic documentation with CDSS enhances various aspects of care such as screening, diagnosis, and treatment. CDSS is helpful in medication administration and uptake, thus enhancing the overall quality of care and outcomes for the patients. These findings suggest that implementing CDSS in providing overall care will improve the quality of services offered, and the safety of the patients will be enhanced. According to this article, a Clinical decision support system is vital in nursing practice and interdisciplinary collaboration in healthcare. This system reduces the work of nurses during the determination and administration of medication. This is usually one of the vital procedures, and incorporating CDSS has assisted in executing the major part of this procedure. Interdisciplinary collaboration is also enhanced since the information needed to deliver care is readily documented by CDSS. This article is useful since it exhibits how CDSS documentation is vital in delivering high-quality care.
Recommendation
From the four resources above, it is evident how the clinical decision system is vital in healthcare systems; CDS helps in the documentation of patient information which will be used for diagnosis and treatment purposes. With this system, the quality of healthcare services has improved, and so does the patient’s safety. Therefore, it is essential to implement CDS in all healthcare institutions for improved care. Certain organizational factors influence the selection of technology in healthcare. Resource availability is the factor that determines the type of technology to be implemented. The presence of training programs and commitment are other organizational factors that influence the adoption and success of healthcare technologies. Social norms are the least effective factor in influencing the adoption of technology. Healthcare technology is not affected by the norms of the employees in healthcare institutions.
The implementation of and the use of technology in a healthcare setting is appropriate. With advances in the technological world, this knowledge has helped enhance medical research, the quality of services offered, and other indirect benefits. Technology has also helped reduce the workload of practitioners and nurses. Monitoring patients and offering follow-up treatment have also been made easy with modern technology. Using technology is also appropriate for the patient since it saves them a lot of time and resources. Therefore, technology is essential in improving healthcare quality and thus improving patient outcomes.
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