The activity
Shoreline Birth Center is a major metro birth center that delivers the most
babies in the area. According to Shoreline’s website, [Shoreline] “has long
been a leader in caring for women, children and families. Our Birth Center is a
beautiful example of our commitment to providing you with state-of-the-art
healthcare in a warm, soothing environment. And as the hospital that delivers
the most babies in the metro area, our commitment to families is clear. From
our outstanding nursing and medical staff, to our state-of-the-art Level III NICU
and high-risk maternity unit, the Shoreline Birth Center takes every step to
ensure you are comfortable, both physically and emotionally, during your stay
with us.”
Last week the local paper did an article on the nation's high rates of Cesarean
(C-section) deliveries. The journalist featured interviews with Shoreline Birth
Center doctors and patients who either performed or had undergone Cesarean
deliveries. The Birth Center feels that the press will negatively impact their
bottom line and have asked you to review their data and present the facts.
Questions
Patient demographics
1. Describe which, if any, specific demographic data should be collected and why. This
information is found on the Registration Tab.
The specific demographic data that should be collected includes age, ethnicity, gender,
occupation, and address. Age and ethnicity can help us see which groups are more likely
to have C-sections. Gender and occupation might show patterns related to why some
people need the procedure. Knowing where someone lives can tell us if they have a
hospital or birthing center nearby, and it also helps us spot trends in different areas.
Vital signs
2. Describe which, if any, specific vitals data should be collected and why. This information
is found on the Vitals Tab.
The specific vitals data that should be collected are the temp, pulse, respiration, blood
pressure, and pulse oximetry. This information can help doctors decide if someone needs
an emergency C-section or if there are any health issues that need quick attention. It also
helps spot anything unusual in the patient’s health that doctors should keep an eye on.
Medications
3. Describe which medication administration fields, if any, should be collected. This
information is found on the Meds Tab and can be examined by clicking on any administered
medication order.
, The information that should be collected in this field is the drug description, frequency,
and the admin history (dosage, date, name of individual who administered it, and method
of admin). This information is important to ensure that the patient is getting the correct
medication(s) at the right time. It also helps providers keep track of how affective the
medication(s) are and if they present any side effects or adverse reactions(s).
Diagnoses & Problem lists
4. Describe which diagnosis or problem fields, if any, should be collected and why. Problems
and diagnoses are listed together on the Problems Tab.
The description of the diagnosis, immediacy, the name of the provider who made the
diagnosis, and the date it was given should be collected. This information helps give a full
picture of the patient’s health. It makes sure the whole medical team understands any
health or personal challenges the patient may have, so they can give the right care. It can
also show if the patient has any conditions that might lead to needing a C-section.
Visit dates and times
5. Describe which fields, if any, should be collected. This data can be found on the
Encounters Tab in the Account section.
The check-in date, the status, name of the provider the patient saw, and description
(reason for visit) should be collected. Collecting these data will help identify any issues
the patient is experiencing, shows when they occurred, and gives the care team a clear
picture of the care the patient has already received. It can also reveal any pre-existing
conditions that may be affecting the patient’s current health or contributing to the need
for a C-section. In this case, the reason for the visit is fetal distress.
Procedures
6. Describe which fields, if any, should be included for procedures. This data can be found
on the Claims Tab in the Account section.
The claim number, the dates the service was given, the location and provider, and the
status of the procedure, along with the date the status was last updated should be
included in the procedures field. This information helps show what procedures the
patient has had (like previous c-section), when and where they took place, and what kind
of care was given. It’s important to collect this because it connects the billing side of
healthcare with the actual medical care. This helps make sure everything is accurate,
keeps records clear, and supports better, continuous care for the patient.
Test results
7. Describe which fields, if any, should be included for test results. This data can be found
on the Labs Tab.