MODULE 2 - STRUCTURED TERMINOLOGIES

Our clinic uses CPT and ICD-9 codes for coding, we have the ICD codes on the computer and then also have a billing sheet where the level and ICD codes are documented. Many are not in the computer or on the sheet so we have a great billing person who will document for us when using correct medical terminology. We use structured medical and nuring terminologies for the most part, though we also use a lot of shorthand and abbreviations. The physicians actually use the most shorthand and abbreviations and the rest of the clinic adjusts and understands what is being said. Many of the codes and terminology are unknown to our lay front end and medical help. This sometimes will create a problem in the flow of the clinic.

The clinical data base is useful in promoting quality patient care by establishing benchmarks for immunizations and monitoring if are patients up-to-date. Monitoring if diabetics are getting their hemaglobin A1C done, along with eye checks, foot checks, etc. Since multiple providers see the same patient at different times, the codes provide evidence of promoting quality patient care and if not done, then using the information to establish this type of care.

N6004 Module One

1. Presently at my office in West Valley we use Spring Charts as our electronic record. It is very verstatile, we are able to track the client from appointment time, check-in with front desk, check-in with MA and then when the client is ready for the provider. We are also able to access drugs, order lab tests and do the full client record. On the family practice side all three providers use the system exclusively and have computers in all rooms to chart as we go. On the OB/GYN sides, one provider rarely uses the system and one will use for visits outside of OB visits. The biggest problem is that is will frequently shut down, and your note is lost, bummer!

2. I believe that knowing about information technology and management for the DNP graduate is essential in providing excellent service to all of our clients. In reading the book, I have been intrigued at all of the information that is available and what has been done to make IT easier for me, though I feel I know so little. The system and the knowledge of the system will definately increase good client outcome and the ability to use evidence-based practice, which is so important in the changing climate of my diverse population. Also, others are using IT and many are very advanced such as the VA, and we as DNP graduates must keep up this technology in order to communicate with one another for again the best outcomes for our clients.

3. I network with many different advance practice nurses, however, none are in the same system that I am in, (except when I am in the Intermountain Healthcare System) I am very anxious to learn how to do this networking using IT. It will make my job more efficient and give the client the best possible care. Right now, this networking, at times, can be very time consuming. Using this blog for sharing of ideas, some of which we talked about during the chat, will be great. I am looking forward to the process. Thanks.