Technology is a valuable assistance in caring for patients. Nurses who are with the patient on a 24-hour schedule often recognize that it is important and also recognize that the data, which is stored in the clinical information system on each patient, is extremely important in patient care.
Mrs. Jeng is an 89-year-old woman who was found on the floor of her home. She states that she got dizzy and sat on the floor and did not fall. She was brought in for observation and testing. Dr. Gupta reviews the nursing history in the EHR and the patient’s first assessment. While he is placing orders in the chart, he is given an electronic alert by the clinical information system to remind him that he may want to order an MRI of the brain to rule out a CVA. Dr. Gupta cancels the alert because he believes that observation of the patient and reevaluating her in the morning will suffice. As he walks on the floor the next morning, the nurse signals to him frantically to come and see Mrs. Jeng. It appears that she has had a major CVA. Dr. Gupta knows that this may have happened with or without Mrs. Jeng having had the MRI the day before, but he is concerned about the ramifications of his canceling the alert the day before.
Dr. Gupta cancelled that alert because he felt that it was not clinically necessary. How did the CIS (Clinical Information System) “know” that an MRI of the brain is/was an appropriate intervention?
What are the potential ramifications for Dr. Gupta canceling the alert?
Explain the importance of the CIS “knowing” about the history of the patient and the symptoms she was displaying.
Discuss how the nurse might have intervened in the situation.
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