NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Assessment 3: Patient Discharge Care Planning
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Student Name
Capella University
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Course Name
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Prof Name
MARCH 8, 2024
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Patient Discharge Care Planning
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This evaluation centers on crafting Marta Rodriguez's discharge care plan following her recent
hospitalization due to a severe accident en route to college. With a four-week stint in the trauma
center involving multiple surgeries and antibiotic treatment, coordinating Marta’s care is
paramount. In my role as the senior care coordinator, I will present Marta’s case during an
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upcoming interdisciplinary team meeting to discuss her discharge plans.
Longitudinal, Patient-Centered Care Plan
To ensure Marta Rodriguez receives comprehensive, patient-centered care, the interdisciplinary

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team will leverage components of Health Information Technology (HIT) to enhance

communication and coordination throughout her care journey. These HIT elements include
electronic health records (EHRs), secure messaging platforms, telehealth technology, and
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medication reconciliation tools. EHRs will facilitate real-time access and updates to Marta’s
medical records, enabling the development of a comprehensive care plan.
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Secure messaging platforms will streamline communication among team members, especially
regarding changes in Marta’s condition, appointments, and medication schedules. Telehealth
technology will enable remote monitoring of Marta’s vital signs, allowing for early intervention.
Additionally, medication reconciliation tools will ensure the accuracy of her medication list,
thereby reducing medication errors.
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To prevent Marta’s readmission within 48 hours after discharge, the inter-professional team
must ensure Marta receives adequate education, support, and follow-up care. The utilization of
HIT elements can bolster these efforts. For instance, telehealth technology can monitor Marta’s
post-discharge progress, provide virtual support, and identify potential issues that might lead to
readmission. Furthermore, secure messaging platforms can offer Marta timely and accurate
information regarding her medication and follow-up appointments.
Meanwhile, the incorporation of these HIT elements will promote care coordination for Marta by
fostering communication and collaboration among team members. Access to uniform
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information about Marta will enable the development of a comprehensive care plan.
Furthermore, EHRs will allow team members to track Marta’s progress, ensuring she receives
appropriate care throughout her recovery. By harnessing HIT elements, the inter-professional
team can deliver a patient-centered, coordinated, and effective care plan tailored to Marta’s
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unique needs.
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Data Reporting
Data reporting is pivotal in the healthcare industry, influencing care coordination, administration,
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clinical efficiency, and interdisciplinary innovation in treatment. In Marta Rodriguez’s case, data
reporting on her behaviors can enhance the quality of her care and support her recovery in
three key ways:
Care Coordination: Data reporting can facilitate care coordination among inter-professional
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team members by providing a shared understanding of Marta’s condition and progress. For
instance, data on Marta’s medication adherence, vital signs, and symptoms can be reported
through EHRs or secure messaging platforms, enabling effective collaboration in her care
management and reducing the risk of complications or readmissions.
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Care Management: Data reporting can shape care management by identifying areas where
Marta may require additional support or interventions. Information on her pain levels, mobility,
and nutritional status, for example, can be reported to the team, allowing them to adjust her care
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plan as needed to improve its quality and enhance her recovery.
Inter-professional Innovation: Data reporting can drive innovation in inter-professional care by

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providing insights into Marta’s behaviors and preferences. Data regarding her language
preferences or cultural background can be shared with the team, enabling them to tailor their
care to her specific needs, thereby promoting patient-centered care and better outcomes.
To ensure data quality, the team should implement data validation protocols, conduct regular
audits, and provide training on data entry and reporting best practices. Additionally, the data
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must be relevant to Marta’s care goals and aligned with evidence-based practices, allowing the
team to make informed decisions and provide her with the best possible care.
Client’s Record Influencing Health Outcomes
Patient records play a pivotal role in improving health outcomes. Marta Rodriguez’s case
demonstrates how inter-professional teams can leverage Health Information Technology (HIT)
to collect, analyze, and share information from client records, ultimately enhancing patient care
and outcomes. This discussion explores how data obtained from patient records can positively
influence health outcomes and how inter-professional teams can coordinate their efforts using
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HIT.
HIT enables inter-professional teams to gather and analyze data from client records, offering
insights into trends, patterns, and care gaps. For instance, Marta’s records can provide valuable
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information about her medical history, medication regimen, and health status, facilitating the
development of a comprehensive care plan tailored to her unique needs. HIT can also help
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identify potential risks, such as adverse drug reactions or postoperative complications, enabling
prompt intervention to prevent negative health outcomes.
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Moreover, HIT enhances care coordination among inter-professional team members. By sharing
information from client records, team members can collaborate more effectively in managing
patient care. Tools like EHRs and secure messaging platforms enable real-time communication,
ensuring that all team members are up-to-date with the latest patient information. This reduces
the risk of miscommunication and errors, ultimately leading to improved health outcomes for the
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patient.
Effective coordination of findings among inter-professional team members requires clear

communication, a shared care plan, and a willingness to collaborate toward common goals. HIT
tools provide a centralized platform for accessing and sharing information, ensuring that all team
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members have a comprehensive understanding of the patient’s care needs. This collaborative
approach enables the provision of holistic care that addresses all aspects of the patient’s health,
resulting in better health outcomes.
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Positive health outcomes can be influenced by the use of HIT to collect, analyze, and distribute
data from patient records. Inter-professional teams can utilize HIT tools to coordinate their
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efforts, ensuring access to the latest patient information. Through effective collaboration and the
proficient use of HIT tools, these teams can provide patient-centered care that comprehensively
addresses all aspects of the patient’s health, leading to improved health
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References
Brooks, E. M., Winship, J. M., & Kuzel, A. J. (2020). A “Behind-the-Scenes” look at
inter-professional care coordination: How person-centered care in safety-net health system
complex care clinics produces better outcomes. International Journal of Integrated Care, 20(2).
https://doi.org/10.5334/ijic.4734
Chowdhury, D., Hope, K
. D., Arthur, L. C., Weinberger, S. M., Ronai, C., Johnson, J. N., & Snyder, C. S. (2020).
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Telehealth for pediatric cardiology practitioners in the time of COVID-19. Pediatric Cardiology,
41(6), 1081–1091. https://doi.org/10.1007/s00246-020-02411-1
Flickinger, T. E., Waselewski, M., Tabackman, A., Huynh, J., Hodges, J., Otero, K., Schorling,
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K., Ingersoll, K., Tiouririne, N. A.-D., & Dillingham, R. (2022). Communication between patients,
peers, and care providers through a mobile health intervention supporting medication-assisted
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treatment for opioid use disorder. Patient Education and Counseling.
https://doi.org/10.1016/j.pec.2022.02.014
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Leslie, M., & Paradis, E. (2018). Is health information technology improving inter-professional
care team communications? An ethnographic study in critical care. Journal of Interprofessional
Education & Practice, 10, 1–5. https://doi.org/10.1016/j.xjep.2017.10.002
Oksholm, T., Gissum, K. R., Hunskår, I., Augestad, M. T., Kyte, K., Stensletten, K., Drageset, S.,
Aarstad, A. K. H., & Ellingsen, S. (2023). The effect of transitions intervention to ensure patient
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safety and satisfaction when transferred from hospital to home health care—A systematic
review. Journal of Advanced Nursing. https://doi.org/10.1111/jan.15579
Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P.,
Peytremann-Bridevaux, I., & Gilles, I. (2021). An overview of reviews on inter-professional
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collaboration in primary care: Barriers and facilitators. International Journal of Integrated Care,
21(2), 32. https://doi.org/10.5334/ijic.5589
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Schwab, P., Mehrjou, A., Parbhoo, S., Celi, L. A., Hetzel, J., Hofer, M., Schölkopf, B., & Bauer,
S. (2021). Real-time prediction of COVID-19-related mortality using electronic health records.
Nature Communications, 12(1). https://doi.org/10.1038/s41467-020-20816-7
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Assessment 3: Patient Discharge Care Planning

upcoming interdisciplinary team meeting to discuss her discharge plans.

Longitudinal, Patient-Centered Care Plan

To ensure Marta Rodriguez receives comprehensive, patient-centered care, the interdisciplinary

team will leverage components of Health Information Technology (HIT) to enhance

plan as needed to improve its quality and enhance her recovery.

Inter-professional Innovation: Data reporting can drive innovation in inter-professional care by

Client’s Record Influencing Health Outcomes

Effective coordination of findings among inter-professional team members requires clear

Chowdhury, D., Hope, K

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