NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Longitudinal, Patient-Centered Care Plan

In order to provide Marta Rodriguez with longitudinal, patient-centered care, the interdisciplinary team will use HIT components to enhance communication and care coordination across the continuum of care. HIT elements such as electronic health records (EHRs), secure messaging platforms, telehealth technology, and medication reconciliation tools will be used by team members. EHRs will enable the team to access and update Marta’s medical records in real-time, which will help develop a comprehensive care plan for her (Schwab et al., 2021). Secure messaging platforms will facilitate communication among team members, especially regarding changes in Marta’s condition, appointments, and medication schedules (Flickinger et al., 2022). Telehealth technology will enable remote monitoring of Marta’s vital signs, allowing the team to identify potential complications and intervene promptly (Chowdhury et al., 2020). Finally, medication reconciliation tools will ensure accurate medication lists, minimizing medication errors.

To prevent readmission of Marta 48 hours after being discharged, the interprofessional team will need to ensure that Marta receives appropriate education, support, and follow-up care (Oksholm et al., 2023). The HIT elements can support this effort. For example, the team can use telehealth technology to monitor Marta’s progress post-discharge, provide virtual support, and detect any issues that may lead to readmission. Additionally, secure messaging platforms can provide Marta with timely and accurate information about her medication and follow-up appointments.

Meanwhile, using these HIT elements will support the coordination of care for Marta by promoting communication and collaboration among team members. Team members can access the same information about Marta, allowing them to develop a comprehensive care plan for her. Additionally, using EHRs will enable team members to track Marta’s progress over time, ensuring that she receives the appropriate care at every stage of her recovery. By using HIT elements, the interprofessional team can provide Marta with a patient-centered, coordinated, and effective care plan that meets her unique needs.

Data Reporting

Reporting data is extremely important in the healthcare industry since it helps shape care coordination and administration, as well as clinical efficiency and interdisciplinary innovation in treatment. In the case of Marta Rodriguez, data reporting specific to her behaviors can be leveraged to improve the quality of her care and support her recovery. There are at least three ways in which data reporting can shape these aspects of care:

1. Care coordination: Data reporting can facilitate care coordination among interprofessional team members by providing a shared understanding of Marta’s condition and progress (Brooks et al., 2020). For example, data on Marta’s medication adherence, vital signs, and symptoms can be reported to the team through EHRs or other secure messaging platforms, enabling them to collaborate effectively in managing her care. This can lead to more effective and efficient care, reducing the risk of complications or readmissions.
2. Care management: Data reporting can also shape care management by identifying areas where Marta may need additional support or interventions. For example, data on her pain levels, mobility, and nutritional status can be reported to the team, enabling them to adjust her care plan as needed. This can improve the quality of her care and enhance her recovery process.
3. Interprofessional innovation: Data reporting can also drive innovation in interprofessional care by providing insights into Marta’s behaviors and preferences. For example, data on her language preferences or cultural background can be reported to the team, enabling them to tailor their care to meet her needs. This can lead to more patient-centered care and better outcomes.

To evaluate the quality of the data, the team should ensure that it is accurate, complete, and timely. This can be done by implementing data validation protocols, conducting regular audits, and training team members on data entry and reporting best practices. Additionally, the team should ensure that the data is relevant to Marta’s care goals and aligns with evidence-based practices. The team can make informed decisions using high-quality data and provide Marta with the best possible care.

Client’s Record Influencing Health Outcomes

When it comes to improving health outcomes, data collected from patient records is invaluable. The case of Marta Rodriguez illustrates how interprofessional teams can use health information technology (HIT) to collect, analyze, and share information from client records to improve patient care and outcomes. In this rega