NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

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Assessment 3: Patient Discharge Care Planning
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Student Name
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Capella University
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NURS-FPX 6612 Health Care Models Used in Care Coordination
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Prof. Name
Mar 26, 2024

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Patient Discharge Care Planning
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This evaluation focuses on devising discharge care plans for Elena Fernandez, recently
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discharged from the hospital after a severe accident on her way to college. Following a
four-week stay in the trauma center involving numerous surgeries and antibiotic therapy,
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ensuring coordinated care for Elena is crucial. In my capacity as the senior care
coordinator, I will present Elena’s case in an upcoming interdisciplinary team meeting to
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discuss her discharge plans.
Longitudinal, Patient-Centered Care Plan

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To ensure Elena Fernandez receives comprehensive, patient-centered care, the

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interdisciplinary team will incorporate Health Information Technology (HIT) components

to improve communication and coordination throughout her care journey. These HIT
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elements encompass electronic health records (EHRs), secure messaging platforms,

telehealth technology, and medication reconciliation tools. EHRs will facilitate real-time
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access and updates to Elena’s medical records, facilitating the development of a

comprehensive care plan.
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Secure messaging platforms will streamline communication among team members,

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particularly regarding changes in Elena’s condition, appointments, and medication

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schedules. Telehealth technology will enable remote monitoring of Elena’s vital signs,
allowing for early intervention. Additionally, medication reconciliation tools will ensure
the accuracy of her medication list, thereby minimizing medication errors.
NURS FPX 6612 Assessment 3 Patient Discharge Care Planning
To prevent Elena’s readmission within 48 hours after discharge, the inter-professional

team must ensure Elena receives adequate education, support, and follow-up care. The
use of HIT elements can reinforce these efforts. For instance, telehealth technology can
monitor Elena’s post-discharge progress, offer virtual support, and identify potential
issues that might lead to readmission. Furthermore, secure messaging platforms can
provide Elena timely and accurate information regarding her medication and follow-up
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appointments.
Simultaneously, incorporating these HIT elements will promote care coordination for
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Elena by fostering communication and collaboration among team members. Access to
uniform information about Elena will enable the development of a comprehensive care
plan. Furthermore, EHRs will allow team members to track Elena’s progress, ensuring
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she receives appropriate care throughout her recovery. By leveraging HIT elements, the
inter-professional team can deliver a patient-centered, coordinated, and effective care
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plan tailored to Elena’s unique needs.
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Data Reporting
Data reporting holds immense significance in the healthcare industry, shaping care
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coordination, administration, clinical efficiency, and interdisciplinary innovation in

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treatment. In Elena Fernandez’s case, data reporting concerning her behaviors can
enhance the quality of her care and support her recovery in three key ways:
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Care Coordination: Data reporting can facilitate care coordination among

inter-professional team members by providing a shared understanding of Elena’s
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condition and progress. For instance, data on Elena’s medication adherence, vital signs,
and symptoms can be reported through EHRs or secure messaging platforms, enabling
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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
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where Elena may require additional support or interventions. Information on her pain
levels, mobility, and nutritional status, for example, can be reported to the team,
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allowing them to adjust her care plan as needed to improve its quality and enhance her
recovery.
Inter-professional Innovation: Data reporting can drive innovation in inter-professional

care by providing insights into Elena’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 must be relevant to Elena’s care goals and aligned with
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evidence-based practices, allowing the team to make informed decisions and provide
her with the best possible care.
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Client’s Record Influencing Health Outcomes
Patient records play a pivotal role in improving health outcomes. Elena Fernandez’s
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case demonstrates how interprofessional teams can leverage Health Information
Technology (HIT) to collect, analyze, and share information from client records,
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ultimately enhancing patient care and outcomes. This discussion explores how data
obtained from patient records can positively influence health outcomes and how
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interprofessional teams can coordinate their efforts using HIT.
HIT enables interprofessional teams to gather and analyze data from client records,
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offering insights into trends, patterns, and care gaps. For instance, Elena’s records can
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provide valuable 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 identify potential risks, such as adverse drug reactions or
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postoperative complications, enabling prompt intervention to prevent negative health

outcomes.
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Moreover, HIT enhances care coordination among interprofessional team members. By

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sharing information from client records, team members can collaborate more effectively
in managing patient care. Tools like EHRs and secure messaging platforms enable
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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
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leading to improved health outcomes for the patient.

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Conclusion
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Elena Fernandez’s post-discharge care involves a patient-centered approach
characterized by effective coordination. The utilization of HIT elements, including EHRs,
telehealth technology, medication reconciliation tools, and secure messaging platforms,
will enhance communication and coordination across her care continuum. The
significance of data reporting in care coordination, clinical efficiency, and
interprofessional innovation is acknowledged by the team, with high-quality data
providing insights into Elena’s behaviors and preferences, resulting in improved
patient-centered care and outcomes. Client records serve as a valuable source of data
for enhancing health outcomes, and the adept use of HIT assists interprofessional
teams in collecting, analyzing, and sharing this information to develop a tailored care
plan for Elena. The inter-professional team’s effective collaboration will ensure Elena
receives proper education, support, and follow-up care, reducing the risk of readmission
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within 48 hours after discharge.
References
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Brooks, E. M., Winship, J. M., & Kuzel, A. J. (2020). A “Behind-the-Scenes” look at
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interprofessional 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
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Chowdhury, D., Hope, K. D., Arthur, L. C., Weinberger, S. M., Ronai, C., Johnson, J. N.,
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& Snyder, C. S. (2020). Telehealth for pediatric cardiology practitioners in the time of
COVID-19. Pediatric Cardiology, 41(6), 1081–1091.
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https://doi.org/10.1007/s00246-020-02411-1
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Flickinger, T. E., Waselewski, M., Tabackman, A., Huynh, J., Hodges, J., Otero, K.,
Schorling, K., Ingersoll, K., Tiouririne, N. A.-D., & Dillingham, R. (2022). Communication
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between patients, peers, and care providers through a mobile health intervention
supporting medication-assisted 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

interprofessional care team communications? An ethnographic study in critical care.
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Journal of Interprofessional Education & Practice, 10, 1–5.

https://doi.org/10.1016/j.xjep.2017.10.002
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Oksholm, T., Gissum, K. R., Hunskår, I., Augestad, M. T., Kyte, K., Stensletten, K.,
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Drageset, S., Aarstad, A. K. H., & Ellingsen, S. (2023). The effect of transitions
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intervention to ensure patient 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
interprofessional collaboration in primary care: Barriers and facilitators. International
Journal of Integrated Care, 21(2), 32. https://doi.org/10.5334/ijic.5589
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).
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https://doi.org/10.1038/s41467-020-20816-7
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Assessment 3: Patient Discharge Care Planning

Mar 26, 2024

discuss her discharge plans.

Longitudinal, Patient-Centered Care Plan

To ensure Elena Fernandez receives comprehensive, patient-centered care, the

interdisciplinary team will incorporate Health Information Technology (HIT) components

elements encompass electronic health records (EHRs), secure messaging platforms,

access and updates to Elena’s medical records, facilitating the development of a

Secure messaging platforms will streamline communication among team members,

particularly regarding changes in Elena’s condition, appointments, and medication

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

To prevent Elena’s readmission within 48 hours after discharge, the inter-professional

coordination, administration, clinical efficiency, and interdisciplinary innovation in

Care Coordination: Data reporting can facilitate care coordination among

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

postoperative complications, enabling prompt intervention to prevent negative health

Moreover, HIT enhances care coordination among interprofessional team members. By

leading to improved health outcomes for the patient.

Leslie, M., & Paradis, E. (2018). Is health information technology improving

Journal of Interprofessional Education & Practice, 10, 1–5.

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