Clinical Management: Transforming the Assessment Process

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Karen Utterback By Karen Utterback 
Vice President, Product Marketing and Strategy, McKesson

Clinical Management Transforms AssessmentIn a previous post, medical ethnographer Monique Lambert described the time­-intensive, home­grown methods QA staff sometimes employ to complete compliant care plan documentation.

As part of her study, Lambert also has conducted baseline studies of field nursing staff who are not yet using the clinical management functionality in McKesson Homecare™.

Lambert, medical ethnographer and investigator with the David Druker Center for Health Systems Innovation at the Palo Alto Medical Foundation, says she observed varying practices used by nurses to document their patient assessments.

One nurse completed the majority of her documentation for a start of care visit, including vital signs, interventions and assessment findings, directly on the computer in the patient’s home at the point of care.  A second nurse, who also completed a start of care visit, jotted notes on a sheet of paper while in the patient’s home, and then documented the start of care visit after returning to the office.

For field staff, the adoption of the clinical management functionality in McKesson Homecare represents a wholly new way of documenting at the point of care. Some clinicians may experience difficulty adapting to the shift from forms- to assessment-based documentation. However, assessment-based documentation is more consistent with the way nurses are trained to assess patients. Who got into the nursing field because they wanted to fill out forms?

“Technology is not a silver bullet,” Lambert says. “Providers who attend to the interplay between people, practices and technology are poised to realize the full benefit of next-generation healthcare information technologies.”

We believe that the clinical management functionality in McKesson home health software helps transform not only the delivery of care, but also how clinicians approach their jobs. But the proof will come as Lambert conducts follow­up studies.

“I can’t wait to see how McKesson Homecare’s assessment-based orientation to clinical documentation impacts field clinicians,” Lambert says.

I can’t wait either.

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