Clinical Flow Sheet and Problem List
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Today we will discuss what clinical flow sheets are and the purpose of utilizing them in the health care industry. We will also cover the importance of the problem list for documenting symptoms of patients and anything else that may be relevant to their current condition. Studies show that pictures have been far more effective when it comes to explaining minor details or even workflow than just written outlines of the steps taken to accomplish task in the health care industry. I like this concept because it is a good way to monitor the work ethics of a health care facility that can be examined by the board of health industries.ra
A clinical flow sheet in a patient record is a graphic summary of several changing factors, especially the patient’s vital signs or weight and the treatments and medications given. In labor the flow sheet displays the progress of labor, including centimeters of cervical dilation, cervical effacement, position of the baby’s head, baby’s heart rate, frequency of contractions, mother’s temperature and blood pressure, and medications given or procedures performed (Elsevier, 2009) The purpose of the clinical flow sheet is to place the patients information by relevance as a reminder of the health care service provided met the expectations of the facility or health industry board.
Basically the clinical flow sheet will state all vital signs, current weight, medications administered, and procedures performed to show the steps taken at the time the patient was in to be reviewed by management to see that everything possible to fix the health issue was done in a proper and orderly fashion. If it was the police department, the flow sheet is similar to a police report. The arresting officer would have to write a report to the chief of police of everything that happened on the scene step by step. Although these reports can become lengthy at times, Clinical flow sheets are brief and precise of the steps taken during providing health care service to patients.
Problem lists are used to track both acute and chronic conditions related to the care of the patient (Garlee, 2012). The purpose of the problem list is to ensure that everyone who touches the patient knows what conditions are present (Garlee, 2012) The problem list is important because it ties everyone involved in providing health care all understand the same circumstances that exist to prevent medical errors. It is stated in the text, that all clinic staff should be able to easily see the current problems for a patient and view the history of problems. Please note, that the conclusion or diagnosis is not a problem to be listed in the problem list portion of the patient medical record. It is important to not confuse diagnosis with problems, they are not the same. The problem list is important because it is an updated version of the current status of the patient. The problem list is always updated during each patient visits to the doctor, and prior to any blood work or procedures are done on patients.
The problem list is also important because symptoms are liable to change or fluctuate in between doctor visits. That is why problem list are update every doctors visit. Problem list can be viewed to see what symptoms are trending and what symptoms are regressing. Problem list are important in this sense so health care providers can prioritize patient symptoms as those that are trending to become top priority and those that are fading away to be low priority. Today we discussed the utilization of clinical flow sheets and how they can affect health care quality. In my opinion the usage of clinical flow sheets increase the integrity of a health care provider, by just knowing their work ethics are being documented for review by the health board. Problem lists are important because they hold current information of patient’s conditions and prior procedures success and failure rate. This information is essential when it comes to scheduling procedures or major surgery, to match up with the risk factors that already exist from the operation alone. So I ask you, will you get a second opinion on the workflow that was performed on you on your next doctor’s visit? Will you ask to see your problem list of all symptoms that exist in your current condition?
Mosby’s Medical Dictionary, 8th Edition, 2009, Elsevier
Electronic Health Records: Understanding and Using Computerized Medical Records, 2nd Edition, by Richard Garlee, Published by Prentice Hall, 2012, Pearson Education, Inc.