The Johns Hopkins Hospital (JHH) [founded in 1889] is a biomedical research and teaching hospital associated with the Johns Hopkins Medical School. It is based in the United States of America, in Baltimore, Maryland. The hospital is a global pioneer in care delivery, supporting clients in the Baltimore community and all over the globe. Johns Hopkins Hospital and Medical school are regarded as the pioneering institution of current American medical science. They also gave birth to a number of well-known medical procedures, including rounds, house staff and residents. Today, the hospital has over 1000 doctors and over 2000 RN. The hospital serves nearly 148,000 adults and children every year (Matsos, 2022) [ this applies to the Maryland Home Care] only.
Vital signs taking and documentation is a common practice in Johns Hopkins Hospital. In the hospital, vital signs taking and documentation falls within the scope of practice for all health care providers; however, it is a primary routine practice for nurses. Vital signs are an essential component of monitoring the status of a patient in the hospital since they allow for the early detection of delayed prognosis or adverse occurrences (Weenk et al., 2017). A patient’s vital signs are measured to obtain fundamental indicators of the patient’s overall health status. The ability to take clear and accurate vital signs aids the acute medical physician in getting answers about the patient’s history of prevailing illness, guides the physician during the medical examination, and is thus critical in arriving at a definitive diagnosis and creating an effective treatment regimen promptly.
Health information technology (HIT) is defined as the usage of data processing, encompassing both software and hardware (computer), that focuses on storing, recovering, distributing, and using healthcare data, information, and skills for dialogue and tactical decision-making in the healthcare sector. In addition to simplifying communication between health care providers, health information technology (IT) also has the potential to improve drug safety, monitoring, and documentation and promote quality of treatment by optimizing accessibility to and compliance to recommendations (Alotaibi & Federico, 2017). To ensure successful implementation of health information technology, it is necessary to consider various factors, including; Communication both inside and outside the system, component integration, and the system’s interaction not only with other technology but also with individuals, procedures, and workplace structure.
The current global technological advancement has enabled the digitalization of vital signs recording and monitoring. A good example of health information technology in the Johns Hopkins Hospital is the incorporation of Health Connect (EPI) for the documentation of vital signs. Epi Info is free and open-source to collect interoperable software tools created by the Center for Disease Control and Prevention (CDC) to benefit public health professionals and researchers globally (PCNASP EPI Info™ Data Collection Tool, 2020). Epi Info has been in operation for more than two decades and is currently accessible for Android, Microsoft Windows, and apple devices, as well as a web and cloud version of the software. The tool provides for the construction of electronic surveys and the entry and analysis of data.
In the Johns Hopkins Hospital, EPI allows public health professionals who do not have a background in information technology to create simple data entry forms and databases for vital signs, to have a customized experience in data entry, and to conduct analyses of data using statistics on epidemiology, graphs and maps without having to learn a new technology. Investigations of an outbreak by the development of two semi disease surveillance technology, the evaluation, visual analytics, and reporting elements of complex networks, and continuing medical education in the scientific knowledge of epidemiological studies and analytic methods in public health fields around the world are all made possible through using Epi Info.
A manual vital signs documentation system is a type of bookkeeping system in which records are maintained by hand instead of using a computer. The information is manually bundled up into a collection of health record statements instead of being written down in journals, as with most medical records. Tradition manual documentation dictates that vital signs and a blend of self-reported healthcare data and diagnosis findings be maintained on paper-based media (Fuller et al., 2018). The benefits of using manual vital signs documentation include a reduced upfront cost. When it comes to manual vital signs documentation, all needed to start is some paper, some folders, and a closed cabinet to keep all of the records safe and secure. However, that is not as expensive as an electronic health record (EHR) system, which needs servers and other high-end technology to function well. There is also no longer a need for expensive training courses to educate doctors and nurses on the difficulties of managing EHR. These costs arise due to the implementation of an electronic health record (EHR) and the induction of a new healthcare worker.
Another benefit of using manual vital signs documentation is that it is easy to customize medical records to the hospital or doctor’s requirement without a technical overhaul. A physical file containing all previous vital sign data and patient history is consistent and accessible in one place. Furthermore, the information is passed physically from one person to another without difficulty. However, the last notes must be well-written, well-organized, and readily available for this to happen. This is unlike electrical health records, which will require the hiring of an engineer to make changes to the back-end and code systems. Both time and money will be wasted in this manner.
The negative aspects of using manual vital signs documentation include: There are no data backups and there is limited security for stored data. The loss of manual vital signs data files is irretrievable, especially once they have been deleted or corrupted. Even if a criminal group manages to acquire access to electronic records with backup data and storage, there is still a recovery option. There is no productivity from the lost or mixed-up manual vital signs data files. Various shortcomings in the critical signs data files may also result in lost productivity. Multiple departments at a healthcare center become affected by this. Time is wasted looking for misfiled charts (Fuller et al., 2018). The delivery of paper records to a specific location necessitates the time of staff employees. If the paper record isn’t readily available, the administrative staff in charge of filing documentation may have to repeat the process numerous times before it’s done. Medical errors can occur if staff members make choices based on incomplete information.
The expense of duplication of the vital signs records is incurred since it necessitates the purchase of copying and paper supplies and the hiring of personnel to generate and distribute the copies. Staffs involved in assembling, filing, retrieving, and distributing hard copies of vital signs filling forms also require payments, an extra production cost (Fuller et al., 2018). To store paper documents, valuable space that may be better employed has to be devoted to this endeavor. To maintain the physical integrity of the documents, they must also be safeguarded from water, fire, and improper handling of the paper.
The storage of patient data isn’t scalable with manual vital sign documentation. As opposed to electronic medical records maintained on cloud servers, paper medical records require physical storage space for storage purposes (Skyttberg et al., 2018). Furthermore, the lack of access to the documents is a significant source of concern. For example, a patient’s temperature chart can only be used by one person at a time, and it must be kept in a single area. Staff who need access to the data must wait until they are ready. This makes changing the written record more difficult, especially for a patient’s active chart and travels with the patient to the treatment facility. There is a risk of losing or misplacing documents given by hand to the patient’s temporary location. Access to the chart is delayed, which impacts treatment and rehabilitation procedures.
Manual vital signs documentation has the disadvantage of fragmentation created by manual health records. Patients’ medical records get fragmented as a result of multiple meetings with different healthcare professionals. A lack of information flow between patient vital signs records due to disparate records documentation makes it difficult to compile a patient’s longitudinal medical history (Skyttberg et al., 2018). Patients’ general health information is only available to a small number of providers or facilities at a time. Although some minimal communication between referring and consulting physicians may be provided, it is solely for the purpose of that particular session.
Automatic recording of vital signs can be used to curtail the adverse effects of manual vital signs documentation. EPI is a classic example of available software that can be used in the automatic documentation of vital signs. By increasing care coordination, automatic recording of vital signs systems can help to reduce fragmentation of care and improve patient outcomes. It is possible that automatic recording of vital signs may allow for the integration and organization of patient health information and the immediate sharing of that information among all authorized providers participating in a patient’s care. Automatic recording of vital signs alerts, for example, can be used to tell providers the stay of a patient in a hospital and their vital signs progress.
When a catastrophic event occurs, automatic vital signs data are significantly more secure than manual vital signs records because they are not at risk of being compromised. Because each entry log is constant with an individual, it is also easier to maintain responsibility in the health records due to this method (Skyttberg et al., 2018). This aspect makes it easy to keep track of a patient’s medical history and the recommended medical outcomes for the individual patient. It is generally easier to read an automatic recording of vital signs than it is to read an individual’s handwriting. This reduces the chances of misinterpretations and mistakes, which can severely impact the overall patient care quality. Furthermore, when healthcare personnel have access to complete and precise vital sign data, patients receive better medical care. The ability to diagnose diseases and reduce or even avoid medical errors can be increased by employing automatic documentation of vital signs, which can improve patient outcomes.
Automatic recording of vital signs is far more convenient and efficient than manual vital signs. As a result, automatic vital sign recording can lower organizational costs by removing the need for transcriptions, coding, physical chart collection, claims management, and facilitating coordination and reducing the time it takes for the exchange of hard-copy between healthcare providers (Skyttberg et al., 2018). Furthermore, automatic recording of vital signs can minimize the need to store papers in cumbersome file cabinets, allowing for more room in the office to be used for medical equipment and supplies and other needs such as filing cabinets.
Automatic vital signs documentation eliminates copy-pasting of clients’ data and feeling them in place of another patient. Ideally, with automatic vital signs documentation, each patient has to be subjected to the vital signs taking process. The process makes it difficult to copy and paste other patients’ data, unlike manual vital signs documentation where, health care workers can fabricate other patients’ values. Furthermore, constant monitoring of vital signs data collection provides more personalized care, which allows physicians to handle health issues more proactively (Skyttberg et al., 2018). It is possible to analyze and aggregate patient data to alert healthcare practitioners about more significant health trends, such as potential outbreaks and illness trends and individual patient data.
In conclusion, vital signs documentation is an essential routine that health care providers incorporate into their practice and patient care. Ideally, vital signs act as crucial health determinants that illustrate the pattern of diseases. As indicated earlier, any illness is likely to alter one of the four primary vital signs. Consequentially, health care providers can come up with medical diagnoses by interpreting vital signs figures and combining them with the patients’ presentation. It is equally important to acknowledge an era where vital signs documentation was done manually. Manual documentation of vital signs was significant, especially in storing patients’ data in a cheap system. However, manual documentation has its flaws, especially in this new technological age. Issues regarding patients’ data accessibility and availability, scalability of data storage and expense of constant purchase of recording stationaries result in a shift to a digital system of vital signs documentation. Automatic vital signs recording system is proven to be more advantageous than the old traditional manual system. With automatic vital signs recording, patient data safety is guaranteed. A decrease in fragmented information flow and data can also be verified if nurses are unable to vital signs figures. Consequential, healthcare providers can eliminate unnecessary errors that result from inaccurate vital signs readings. However, although automatic vital signs documentation has been effective, the technology always has its disadvantages. Hospitals require appropriate capital to install and maintain the systems with automatic vital signs. Furthermore, there is always the danger posed to the patients’ data privacy in case of a systematic overhaul.
References
Alotaibi, Y., & Federico, F. (2017). The impact of health information technology on patient safety. Saudi Medical Journal, 38(12), 1173-1180. https://doi.org/10.15537/smj.2017.12.20631
Centers for Disease Control and Prevention. (2020, December 15). PCNASP EPI Info™ Data Collection Tool. Centers for Disease Control and Prevention. Retrieved March 21, 2022, from https://www.cdc.gov/dhdsp/programs/framework_data_collection.htm
Connor, N., McArthur, D., & Camargo Plazas, P. (2020). Reflections on vital sign measurement in nursing practice. Nursing Philosophy, 22(1). https://doi.org/10.1111/nup.12326
Fuller, T., Fox, B., Lake, D., & Crawford, K. (2018). Improving real-time vital signs documentation. Nursing Management, 49(1), 28-33. https://doi.org/10.1097/01.numa.0000527716.05512.4e
Matsos, S. (2022, February 16). About Johns Hopkins Medicine. Johns Hopkins Medicine, based in Baltimore, Maryland. Retrieved from https://www.hopkinsmedicine.org/about/
Skyttberg, N., Chen, R., & Koch, S. (2018). Man, vs machine in emergency medicine – a study on the effects of manual and automatic vital sign documentation on data quality and perceived workload, using observational paired sample data and questionnaires. BMC Emergency Medicine, 18(1). https://doi.org/10.1186/s12873-018-0205-2
Weenk, M., van Goor, H., Frietman, B., Engelen, L., van Laarhoven, C., & Smit, J. et al. (2017). Continuous Monitoring of Vital Signs Using Wearable Devices on the General Ward: Pilot Study. JMIR Mhealth And Uhealth, 5(7), e91. https://doi.org/10.2196/mhealth.7208
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