Monitoring, Review and Evaluation Case Disposal Within patient care institutions, clinical care processes are fairly standard, despite the vast array of clinical specializations. While different specialties serve different patient types, the basic tasks and data needs are the same.
The entire clinical processes may be completed during a visit or may be stretched across several visits. Often, all or part of these steps is iterative cyclical , being repeated as progress is reviewed, usually at each outpatient visit or as often as is required during an inpatient stay. There is no need for different systems to be built for each clinical specialty or service setting. The main steps are: Data collection gathering, capture, input, entry Data storage accumulate and make available Data extraction retrieval, output Data presentation display, view Data analysis and interpretation use With the use of computers and databases, these processes become more organized and standardized.
Most importantly, the storage of data in a database allows for data sharing, data aggregation and data analysis. It also enables the computation of data to create derived data e. These data management steps are illustrated in the flow chart below: The CIS make it possible to plan tasks and to gather data that is generated when the tasks are performed.
It also enable descriptions of unplanned clinical events to be recorded. These data are accumulated in the pool of data regarding the patient, termed as the Patient Information Database, from where it can be retrieved when needed.
The former facilitate the administrative functions of patient care. They submit results to the Patient Information Database via the relevant Clinical support applications software. The exception is when they provide care directly to patients e. Provision of the means of communications between the two groups of care providers via the Order Entry system Transfer of results from the clinical support applications to the database of patient data the Result Reporting mechanism Provision of relevant summarized clinical information to clinical support personnel to assist them perform their work An important function of CIS is to help create the Medical record.
It is still a record of pertinent data regarding an individual patient arranged in a chronological order. However, the way the EMR is created is quite different. Because data is captured in a database and usually in a structured form, the pertinent data making up the EMR is extracted from the database and rendered into a format that satisfies medico-legal and professional requirements.
The functions and components of the system to facilitate direct patient care are as depicted below: Functions of CIS All the above functions are provided as modules within a fully integrated system.
The CIS facilitates clinical operations work including the planning of care, implementation of care, quality control and the capture, storage plus distribution of clinical data. In reality, all the functionalities are intricately intertwined throughout the CIS. Care plans embedded in the CIS anticipate the needs of the clinician in delivering care for various patient types and provide direction to the clinician on tasks to be performed according to scenarios, occasions and events. For this purpose, the CIS has the following capabilities: Clinical Governance Committee and other care providers of that particular health care facility.
In the CIS, Care Plans take the form of sets of care packages made up of tasks arranged, sequenced, bundled together and scheduled according to work flows.
The tools provide the means to: Arrange, sequence and schedule sets of tasks according to work flows or care pathways Put together various orders to create care sets that will initiate the above tasks Fashion and furnish guides on how a task is to be performed Design documentation forms or charts for the capture of data generated by the planned tasks It is also expected that modifications of care plans already provided and those newly developed will be endorsed by the clinical governance body of the hospital.
Therefore, Care plans are designed and constructed such that the contents and their arrangement caters for various groups of patients categorized mainly according to the diagnosis and its ramifications stage, severity, effect and complications.
The application software have the capability of linking an appropriate plan to a documented diagnosis. Because the accuracy and specificity of the diagnosis changes with time and with the data available, any change in the diagnosis warrants triggers a change in the content of the Care Plan. Intestinal obstruction, Obstructive jaundice or Bradyarrythmia a diagnostic related group DRG a specific disease Hence, Care Plans are designed for the stage when the diagnosis is uncertain symptom complex, syndrome, disease group and also for the case types where the diagnosis is certain specific illness.
Care plans are also made available for specific treatment programmes e. Modules are also created for various severity levels and patient profiles. The entire overall Care Plan needs to be available for reference especially for the care provider who is overall-in-charge the primary provider or case manager.
Data collection tasks e. Clerking or Assessment using a specific clerking form and Progress reviews guided by various note types. To achieve this the care plan for a health problem is broken further into modules which are provided at the right time.
Division of care into periods phases The chosen diagnostic or therapeutic modality Predicted anticipated events or outcome The system also enables care providers to vary the composition of content in response to: This sequence is not necessarily linear but is dependent on alternative decisions and choices of modalities, besides other factors.
To some extent these phases coincide with different stages in the natural history of the disease. By taking into account the needs of every phase, the plan is divided into modules. The CIS enables the automatic or manual execution of a module at each change-over point of the phase.