Mobile Documentation For Physicians In Hospitals: Needs And Importance

Types of Documentation in Hospitals

This study aims to provide information about the needs and important of mobile documentation for Physician in hospitals. It has been observed that physician in hospitals are spending more time in preparing documentation rather than take direct care of the patients. Therefore, this study provides the outline of current documentation process of hospitals by physician and the possibilities of assessing mobile documentation in their process along with the develop concept and security issues.

Documentation of medical record is an important requirement of every hospital. It is required for the purpose of recording pertinent facts, observations and findings about a patient’s health history (Blair & Smith, 2012). It documents the details of the present and past illnesses, treatments and tests of the patients. Health documents play a significant role in contributing to the quality of patient care that is carried out in the hospitals.

a) Responsible Person for Documentation in Hospital (Who Documents?)

The physicians are responsible for documenting the medical history of the patients that will contain evidences of the physical examinations (Calloway, Akilo & Bierman, 2013). Physicians spend most of their time in documenting about the diagnosis, treatments, procedures and investigations for every treatment that is carried out (Timimi, 2012). The physicians are also responsible for documenting the medical management plan of the hospital. Copies of certificates that are provided to the patients are also documented by the physicians.

b) Various Process of Documentation (How Documents?)

In the hospitals, there are several types of documentation that taken place. These are the followings –

A) Medical Record: This record consists of the patient details along with diagnosis details. It contains the result of treatments so that it facilitates future care of the patients. The medical practitioner is responsible for maintaining the medical records of the patients and for regular updates so that appropriate care of the patients can be carried out in the hospital (Devkaran &O’Farrell, 2014). This record is documented from the time when the patient is admitted to the hospital till the time of discharge. It is updated on a regular basis by the physicians and medical practitioners (Haux et al., 2013). The medical record is generally documented manually by the physicians present in the hospital.

B)  Physical Examinations and History Record: It is the responsibility of the physicians or Allied Health Professionals to perform physical examinations and admission history of the patients (Swartz, 2014). This H&P record must be completely updated before any surgery or other invasive procedures.  It contains information about the present illness, past medical details, physical examinations and its results. It also contains the action plan that needs to be carried out for carrying out the treatment of the patients. Documentation procedure is carried out manually in the hospitals.

Evaluation of Current Process for Gathering Required Data

Consider a situation when complete history of the patient is not documented before the surgery. In this case, the surgeon needs to first complete the documentation procedure before carrying out the operation. Invasive procedures like OR procedures, endoscopies, tubal ligations and ambulatory surgeries must include H&P record (Williams et al., 2014). Attending medical staffs and physicians are mainly responsible for documentation of H&P. It needs to be updated on a regular basis by the physicians (Johnson et al., 2014). Dentists are responsible for their patient’s H&P that is related to dentistry. In case of ambulatory surgical patients, this document must contain list of the current medications and other essential information of the patients.

C) Report of the Emergency Department: This report contains time of arrival of the patient, clinical observations, results of treatment, and patient’s condition at the time of discharge, and history regarding the illness along with its physical findings (Taubman et al., 2014). It will also consist of the details of final disposition, instructions for the purpose of follow-up care and treatments. The medical practitioners and physicians who are handling the emergency departments are responsible for carrying out this documentation procedure. The physicians make sure that this emergency record is accurate so that they can analyze this case in the future and further help the patients to recover in an effective manner (Ward et al., 2014). This record is maintained in a file and the information is recorded manually.

D)Progress Report: This document will contain the progress report of the patients. Handwritten notes are used by most of the hospitals for recording the daily health progress of the patients. It will help to provide the health record of the patients in a chronological order. It will help to provide details about the change in the health condition of the patients. 

E) Operative Report: This type of report is documented after the completion of an operative or high risk procedure before transferring the patient to the next level of treatment and care (Mamykina et al., 2012). Operative reports are prepared and documented by the surgeons who carry out the operations and high risk procedures.

F) Discharge Summary: This is a document that contains information regarding the reason for admission of the patient, summary of the diagnosis, patient’s condition and the instructions that are given to the patient about further diet and medication (Pollard et al., 2013). The discharge summary of the patients needs to be documented within 24 hours after the discharge has taken place (Lenert, Sakaguchi & Weir, 2014). This documentation is carried out by the practitioner who was responsible for the medication of the patient.

Modifications needed within Healthcare Organizations

G)Transfer Summary: This report needs to be documented when patients are transferred from one unit to another unit for the purpose of further treatment and care. The transferring physician is responsible for carrying out the documentation of the transfer summary. The transfer summary will contain details about the reason for the transfer, summary of the treatments, cares and services that are provided to the patients. It will also contain details about the progress of the health of the patient and the risks or benefits for transferring the patient to another unit or hospital. The transfer summary can act like a guide to the next physician who will be responsible for the patient’s treatment and medications (Gregory &Radovinsky, 2012). It will also contain the psychosocial and physical status of the patient. This document is present in the form of files that is manually completed by the physician.

c) The Time of Documentation (When Documents)

Physicians generally document the medical details of the patients after examining the health condition of the patients. Sometimes the health history of the patients is also recorded by the physicians. The physical examination and health history of the patients are documented in the medical record of the patients within 24 hours from the time of admission or during the time of registration. Emergency report needs to be completed within 1 day or approximately 24 hours from the time of discharge or disposition of the patient from the emergency department of the hospital. Progress report of the patients is updated every 24 hours by the physician after carrying out the regular checkup of the patients. Operative report is documented by the surgeon within 24 hours after the operation has been completed. The transfer summary is completed within 24 hours after the patient has been transferred to another department, unit or other hospital by the transferring physician.

This part of the report concretes on the evaluation of current process for gathering required data. These data are further analyzed to identify the areas that are needed to be modified. Providing the details of modifications and how the modifications can prevent the current concerns is a vital part of the study.

Current Situation and Process:

At present the physicians manually enters data and information that are related to their work. These manual process takes a lot of time of physicians that they could not concentrate on their work. Manual process includes the registration of patients, updating health record and many more. In order to make everything is right and all the data are correct, the physicians have to re-check the entered data. The patients also have to depend on the physicians to know their health related data. This is time consuming and often frustrating for both the parties.

Identification of Modifications:

The first thing that is needed within the organization that is a system that can automatically do the physicians secondary works. Using a data recording system within the organization. This system will be incorporated within the core system and support the organization objective. The system must be able to provide accurate and efficient search option to the physicians. The system must be able to store all the personal and health related data of the patients. As an enormous amount of data will be stored within the system, the functionalities and features of the data recording system must be able to cope with the changing needs. As the first priority is reducing the time of work of physicians and let then concentrate on patient care, the system must be able to provide all the required data to the patients in real time.

The healthcare organizations also focus on including the patients within the picture. The patients must be able to help themselves to gather their updated health record and enter required data. It becomes often difficult for the physicians to register the patients within the system and treatment them at the same time, especially at the time when patients are present in large number. The registration process becomes very lengthy that it affects the main purpose of the physicians. The proposed system must be able to assist the physicians to reduce the time of documentation through giving the patients the responsibility of registration into the system. For this purpose, the healthcare organization must develop a technology that can be user friendly and accessible by anyone. The application will be connected to the main sever and database. Therefore, it will be possible for the patients to gather health data efficiently, without asking anyone.

Another modification that is needed within the healthcare organizations is the collaborations among them. This will be a huge step toward reducing the documentation time of the physicians and increasing the affectivity and efficiency of patient treatment. For this a shared system or server or any other advanced technology can be used.  This technology will be assisting the physicians to gather the data regarding the patients and their treatment history from other healthcare.

Modification:

Implementation of EHR: EHR or Electronic Health Record can be referred to as the digital version of paper chart of patients. The physicians will be able to see the patients’ data in real time and instantly. These data will be provided to the authorized personnel only. The EHR not only contain the histories of the patient care but also the used for going beyond the clinical data collected within a provider’s office. The EHR will be including the information like diagnosis, immunizations dates, history, radiology images and many more.

There are various factors that have to be considered before installing the EHR within the organization. The organization have to make sure that the administrative processes are organized properly. The physicians understand the clinical workflows and it is also mapped properly. The existing system should have proper reporting procedure and data collection process is accurate and efficient. The physicians and other staff that will be accessing the EHR must have proper training to use the system and have adequate amount of computer knowledge. The organization must be able to support the implementation project financially.

The implementation process of EHR is done through ten steps. The processes are as implementation team formation, application configuration, recognizing the requirements of hardware, data transfer, pre-launch workflow optimization, room layout consideration, making the decision regarding the launch of application, building the processes at the time EHR is down. Commencing a plan for training.

The team will be consisting of physicians, compliance office staff, project manager, administrative employee and IT experts. The responsibility of the lead physicians is guiding the implementation process from beginning to end. The physician serves as the connection or link between the end users and project team members. The project manager controls the process of the implementation and directs the project. The IT experts does the base work and develop the system or EHR. Then a HIPAA risk evaluation is done to meet the adequate security measures of the EHR. The EHR will be developed in such a way that it can support documentation for physical. This will be achieved through considering physician specific template. Considering the computerize order entry is another crucial feature that will be used within the EHR for supporting the documentation need of physicians. Through the use of the proper hardware, the time and capital for the implementation can be saved. Each of the physical will be provided a computer that will be connected to the main server through LAN network. The mobile devices will be used for the same purpose, by the physicians, but connected to the Wi-Fi.

These servers will be holding the core application and database. The database will be developed through magnetic discs. The physicians and administer will be creating a checklist to decide which data will be inputted into the system. The IT experts and administrative employees will be deciding the average time to transfer data for an average patient. At this point, this is very crucial to discuss that someone is needed to upload the demographics and past medical, social, family and medication histories of patients so that the documentation effort for the physicians can be reduced. Then the workflows will be optimized for the implantation. The decision will be taken within this process that for which processes the physical will be required training. The IT experts and physicians will be considering the room layout in the next process. As the organizations will be modifying its existing IT system, the incremental approach will be the most feasible way of launching the application within the organization environment. The incremental approach lessens the loss of productivity due to operational and workflow changes from EHR adoption. It needs severely following a work plan to keep execution stages on target.

Implementation of Mobile Application: The mobile application implementation is a critical task within the project. The mobile documentation will be the key factor for the proposed solution. The mobile application will be developed for Android, Windows and iOS platform. The physicians, staff and patients will be using the mobile application. The mobile application will be connected to the system server. This will allow the end users to make the most of use of the system. The patients will be able to register then into the system remotely from any location and arrange an appointment with the physician. The patient can also see the treatment and health history through the use of the mobile application. This will reduce the documentation effort of the physicians significantly.

Security is a huge issues in terms of mobile application usage. The mobile phones are open to the whole cyber world due to using open network. This will lead the cyber criminals to the system. If the mobile device is affected by some virus or spam, it may lead the criminals to the link to the server, various precautions must be taken to prevent the cyber-attacks.

Using Hybrid Cloud and Shared Database Instance: The healthcare organization can collaborate with various other organizations to gather the data regarding the patient history and personal information. If the patient has visited in a partner organization in past, then the history of treatment will be automatically downloaded into the system. Through the use of the Hybrid Cloud and sharing an instance of the cloud database, the organizations can also detect the processes of treatment of various illness. This will not only save the documentation time of the physicians but also assist them in providing better treatment.

First Visit:

At first, the physicians had to register the patients into the system one by one. Through the use of mobile application, the patients will be able to register themselves within the system.

 

Figure 1: Example of Registration Page in Mobile Application

(Source: Lackey et al., 2014, 128)

The patients will be inserting the personal information within the registration page. This information will be transferred from the application to the server through a secure communication medium. These data will be verified by the system based on the checklist that physician and administrative staff has provided. After the successful verification, the patient will be registered. After successful registration, the patients will be able to set an appointment with the physician. All of these data will be stored within the system through an automated process. The physicians do not have to worry about documentation of appointment and check free time. The system will automatically set the appointment on a free schedule. These data will be accessed by both the patient and physician. Any modification needed such as change of appointment can be done by the administrative staff. Therefore, the first visit related any documentation work does not need to be concerned with valuable time of physician.

Second or Further Visit:

The appointment will be scheduled as the same way like the first visit, the patient will request visit and the system will detect a free time for particular physician. In addition to that, if physician feels, after first visit of patient, that further treatment is needed to be done he/she can schedule an appointment and the system will store the appointment related data into the system. The system will be automatically checking the free time of physician so the possibility of setting two or more appointments at same time completely eliminates. The system will have a section that will allow the physician to record update regarding the patient health, new exposure to risk and many more. These data will be verified by the system and if the verification fails the messages will be sent to physician to correct the mistakes. This will not only increase the data accuracy but also increase physician working efficiency. All the blocks will be pre-generated, the physician has to just input the data into the proper area.

 

Figure 2: Example of Patient Health Form in Mobile Application

(Source: Penoyer et al., 2014, p.135)

Documentation and Data Transfer:

The documentation is done in generally in the In patient Department. The use of EHR will be reducing the time of saving the data within the database. The EHR is also effective in transferring the data quickly to various devices connected to the system. As the data will be organized and accurate, the reliability on the system information is high. As the mobile application will be providing access to the system day and night, the availability of the system will be 24*7.

 

Figure 2: Example of Mobile EHR Application

(Source: Lackey et al., 2014, 128)

Security Implementation:

Encryption: Encryption is a reasonably simple idea: the change of information (otherwise named the plaintext) in to a form (called the ciphertext) that’s unintelligible to anyone can you perhaps not possess the proper key. Decryption is the opposite process and works on the critical to transform the ciphertext back once again to the understandable plaintext. Presumably, only the supposed beneficiary has the proper critical, ensuring the confidentiality of the message. When using encryption, the sender and beneficiary must utilize the same mathematical technique (known becoming an algorithm) to execute the encryption and decryption. Encryption algorithms might be split in to two organizations: symmetric and asymmetric, which differ in the manner the encryption keys are used.

Securing Mobile Device: Several contemporary mobile devices include local security options such as for instance like built-in biometrics fingerprint scanners, skin acceptance, voiceprint acceptance and therefore forth but also older units will continue to work well with little, lightweight security tokens (or one-time passwords given through numerous indicates such as for instance like email and automated telephone systems). Beyond a easy bill and password, mobile devices should be combined with numerous kinds of verification to make sure that possession of a lightweight system doesn’t immediately grant application of important info and systems.

Companies or businesses that problem mobile devices to personnel must identify plans to restrict or block use of third-party software. Here is the greater way to prevent probable compromise and security breaches caused by intentional or drive-by installing of rogue software, replete with backdoors and “black gateways” to siphon information in the incorrect hands.

Using Cloud Backup: JustCloud is a easy, rapidly and secure on line storage provider. Just Cloud immediately buttocks up papers, photographs, music and videos stored on a user’s computer to the cloud therefore they are never without their files. JustCloud files are available from everywhere anytime and offers unlimited storage, 100 per cent automated copies and the ability to sync numerous pcs and cellular system apps. JustCloud plans start at $5.61 every month for 75GB, which includes complete information security and 24/7 technical support.

Conclusion

It can be concluded from the above discussion that mobile documentation will allow the physicians to save time. It will enable the physicians to spend more time in direct care of the patients. Mobile documentation will incorporate security features and policies that will enable the physicians to securely share data. The above report outlines the brief description of the concept of mobile documentation that can be programmed in future. This report further describes about the other benefits that the physicians will get from mobile documentation.

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