Does the problem relate to transcriiption and coding?

Words: 440
Pages: 2
Subject: Uncategorized

The course project in Module 04 and 05 is examining a technique that is commonly used for improving communication among team members and patients and develop solutions to solve problems to improve organizational function and patient experience. It is called SBAR and stands for Situation, Background, Assessment, and Recommendation.

For each module, you will be given a scenario that you will have to utilize the SBAR technique to improve communication and develop a solution to the issue.

Scenario
You have been in your position as a medical administrator for 6 months. During this time, you have noticed a disturbing trend in your facilities Intensive Care Unit (ICU). Errors in documenting patient vital signs are increasing which has led to providers having inaccurate information for care and affecting the patients discharge.

You have noticed that the trend in documentation mistakes are always on the respirations (R) and pulse (P). The documentation mistake happened on all shifts and on all computers in the ICU.

The following is an example of a 35-year-old male in the ICU due to fungal pneumonia complicated by COPD. Patient also was in a car accident 2 weeks ago (cause of accident TBD).

Example:

R: 76

P: 16

T: 98.7 F

After reviewing the scenario and using the SBAR technique, please describe the Situation, Background, Assessment, and Recommendation for this patient scenario. Again, remember you are trying to improve communication and resolve a problem.

S=Situation; provide a clear and concise statement of the problem

What is the situation that is occurring? (don’t include the “why” of the problem just yet)
B=Background; utilizing information provided within the statement, provide pertinent information related to the situation

Be sure to include information from the scenario below that supports the situation you described.
A=Assessment; utilizing your critical thinking skills, provide an analysis/assessment of what you found

Think about the Electronic Health Record (EHR). Does the problem include technical difficulties with the EHR and the interface for vital signs monitoring?
Think about additional problems that could occur as a result of the error. Is it user entry error? Does the problem relate to transcriiption and coding? Could their visit be coded incorrectly leading to billing errors?
R=Recommendation; provide action requested/recommended

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