NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

NURS FPX 6612 Assessment 3

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning


Capella University

FPX6612: Health Care Models Used in Care Coordination

Instructor’s Name

March 2024

Patient Discharge Care Planning

This assessment focuses on the intricacies of patient discharge care planning, specifically on Marta Rodriguez’s case. Marta, a recent Nevada transplant student, was engaged in a hit-and-run car accident during her first semester of college that put her in a difficult predicament. As Marta’s senior care coordinator, it is my duty to make sure that her discharge from the shock trauma center, where she had intensive treatment, goes as smoothly as possible. This investigation looks at how health information technology (HIT) can be crucial in creating a thorough and patient-centered discharge plan to maximize Marta’s recuperation and well-being given her particular situation.

Longitudinal, Patient-Centered Care Plan

As Marta’s senior care coordinator, leveraging HIT tools can ensure that her care plan is comprehensive and well-coordinated throughout her recovery journey. Firstly, HIT enables the seamless exchange of patient information among healthcare providers involved in Marta’s care, including the shock trauma center where she underwent surgeries and antibiotic treatment, as well as any subsequent healthcare facilities or specialists she may encounter. By having access to electronic health record (EHR), care team can stay informed regarding medical history, treatment plans, and progress, facilitating continuity of care and preventing gaps in communication (Russell & McNeill, 2022).

Secondly, HIT supports care coordination by providing decision support tools and alerts to guide healthcare providers in delivering appropriate and timely interventions for Marta. For instance, alerts within the EHR system can notify the care team about important updates or changes in Marta’s condition, such as allergic reactions or medication contraindications, ensuring that her care plan is tailored to her specific needs and circumstances. Additionally, decision support systems can offer evidence-based guidelines for managing post-operative care, infection prevention, and rehabilitation, helping the care team make informed clinical decisions that optimize recovery outcomes (Solomon et al., 2023).

Furthermore, HIT enables real-time monitoring of Marta’s progress and facilitates proactive interventions to address any potential complications or setbacks. Remote patient monitoring devices, integrated with EHR, can track vital signs, wound healing progress, and medication adherence, allowing the care team to detect early warning signs and intervene promptly (Alanazi & Daim, 2021). Additionally, data analytics tools can analyze trends in Marta’s recovery trajectory, identify areas for improvement, and inform adjustments to her care plan to ensure optimal outcomes. By harnessing the power of HIT, Marta’s care team can collaborate effectively, provide personalized care, and empower Marta to actively participate in her recovery journey, ultimately enhancing her overall well-being and quality of life.

Through secure messaging systems and telehealth capabilities, healthcare providers can collaborate in real-time, regardless of their physical location, to discuss progress, coordinate care plans, and address any concerns or questions that may arise (Laukka et al., 2020). This interdisciplinary approach ensures that Marta receives holistic and coordinated care, with each member of the care team contributing their expertise and insights to optimize her treatment plan.

Additionally, HIT empowers Marta to actively engage in her own care and decision-making process. Patient portals integrated with the EHR allow Marta to access her health information, review treatment plans, and communicate with her healthcare providers securely. This transparency and access to information enable patients to become a proactive participant in their recovery (Russell & McNeill, 2022). By involving Marta as a partner in her care, HIT not only enhances the effectiveness of the care plan but also promotes patient satisfaction, adherence to treatment protocols, and long-term health outcomes.

Data Reporting

Analyzing data on patient behaviors allows care coordinators and healthcare teams to identify patterns and trends that may impact Marta’s treatment plan. For example, monitoring Marta’s adherence to medication regimens, dietary restrictions, and activity levels can provide insights into her engagement with her care plan and help identify any barriers or challenges she may be facing. By understanding Marta’s behaviors, the care team can tailor interventions and support strategies to address her unique needs and preferences, ultimately improving care coordination and management.

Data reporting on client behaviors enables healthcare providers to track the effectiveness of interventions and measure outcomes related to Marta’s care. By collecting and analyzing data on behaviors over time, the care team can evaluate the impact of various treatment modalities and adjust the care plan accordingly (Laukvik et al., 2022). For instance, if data indicates that Marta’s adherence to physical therapy exercises is correlated with improved mobility and pain relief, the care team may prioritize and reinforce these interventions to optimize Marta’s clinical outcomes. Additionally, data reporting allows for the identification of best practices and evidence-based approaches to care, promoting clinical efficiency and enhancing the delivery of high-quality, patient-centered care for Marta.

Through regular review and discussion of Marta’s behavioral data, healthcare providers from different disciplines can collaborate to develop comprehensive care plans, identify areas for improvement, and innovate new strategies to address Marta’s evolving needs. For example, care team may identify opportunities to leverage technology, such as mobile health apps or telehealth services, to support her self-management goals and enhance communication between office visits (Laukvik et al., 2022). By sharing insights and exchanging ideas based on data-driven observations, the care team can work together more effectively to achieve optimal outcomes and promote Marta’s overall well-being.

In evaluating the quality of data reporting on client behaviors, it is essential to consider several criteria, including accuracy, completeness, timeliness, and relevance. For Marta’s case, accurate and comprehensive data on her behaviors, symptoms, and treatment adherence are essential for guiding care coordination and decision-making. Timely reporting of data allows the care team to intervene promptly and prevent adverse events or complications (Mashoufi et al., 2023). Additionally, data should be relevant to Marta’s specific health goals and aligned with evidence-based practices to ensure that interventions are effective and meaningful. 

Moreover, data reporting specific to client behaviors can support proactive interventions and personalized care planning for Marta. By identifying early warning signs or deviations from expected behaviors, such as changes in medication adherence or increased symptom severity, the care team can intervene promptly to prevent exacerbations or complications (Mashoufi et al., 2023). For instance, if data reveals that Marta’s activity levels have decreased significantly, prompting concerns about potential deconditioning or depression, the care team can implement targeted interventions, such as physical therapy referrals or mental health support services, to address these issues promptly. This proactive approach not only improves clinical outcomes but also enhances Marta’s overall experience of care by addressing her individual needs and preferences in a timely manner.

Client’s Record Influencing Health Outcomes

Client records contain comprehensive data on the patient’s medical history, including past illnesses, diagnostic tests, medications, and treatment outcomes. A thorough review of Marta Rodriguez’s medical records may reveal underlying health conditions, such as diabetes or hypertension, which can inform the development of targeted interventions to manage these conditions effectively and prevent complications.

Information from client records enables healthcare providers to tailor care plans to meet the specific needs and preferences of individual patients like Marta. By considering factors such as age, gender, cultural background, and socioeconomic status, healthcare teams can design personalized interventions that take into account the unique circumstances and challenges faced by each patient (Haleem et al., 2021). For example, if Marta’s medical records indicate that she prefers alternative therapies or has dietary restrictions due to cultural or religious beliefs, the care team can incorporate these preferences into her care plan to promote adherence and improve health outcomes.

Moreover, information collected from client records facilitates proactive interventions aimed at preventing adverse events and complications. Additionally, the collaborative use of health information technology (HIT) enables seamless communication and coordination among members of the healthcare team, leading to more efficient and effective care delivery. By sharing real-time updates and electronic health records, healthcare providers can stay informed about progress, treatment plan changes, and follow-up care needs, ensuring continuity of care across different settings and providers (Ahmad et al., 2021). This interdisciplinary approach fosters collaboration, enhances care coordination, and minimizes the risk of errors or omissions that could negatively impact Marta’s health outcomes.

By maintaining accurate and up-to-date medication lists, allergy information, and treatment protocols in the EHR, healthcare providers can avoid prescribing contraindicated medications or duplicative therapies, thus minimizing the risk of adverse events (Newman et al., 2021). Additionally, clinical decision support tools embedded within the EHR can alert providers to potential drug interactions, dosage errors, or treatment conflicts, enabling them to make informed decisions and prioritize patient safety.

Moreover, the information collected from client records supports continuous quality improvement initiatives within healthcare organizations. The information collected from client records supports evidence-based decision-making and research efforts aimed at advancing clinical practice and improving patient outcomes (Upadhyay & Hu, 2022). By aggregating and analyzing large datasets from client records, researchers can identify trends, associations, and predictive factors related to disease prevalence, treatment effectiveness, and healthcare utilization patterns. 

NURS FPX 6612 Assessment 3


The utilization of health information technology (HIT) in patient discharge care planning, particularly in Marta Rodriguez’s case, underscores its transformative potential in enhancing care coordination, improving patient outcomes, and promoting a seamless transition across the continuum of care. By harnessing HIT elements effectively, interprofessional teams can streamline communication, access real-time patient data, and implement evidence-based interventions tailored to Marta’s needs. The strategic adoption of HIT stands as a cornerstone in fostering patient-centered care and advancing the quality and safety of healthcare delivery.


Ahmad, R. W., Salah, K., Jayaraman, R., Yaqoob, I., Ellahham, S., & Omar, M. (2021). The role of blockchain technology in telehealth and telemedicine. International Journal of Medical Informatics, 148, 104399. https://doi.org/10.1016/j.ijmedinf.2021.104399 

Alanazi, H., & Daim, T. (2021). Health technology diffusion: Case of remote patient monitoring (RPM) for the care of senior population. Technology in Society, 66, 101662. https://doi.org/10.1016/j.techsoc.2021.101662 

Haleem, A., Javaid, M., Singh, R. P., & Suman, R. (2021). Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sensors International, 2(2). https://doi.org/10.1016/j.sintl.2021.100117 

Laukka, E., Huhtakangas, M., Heponiemi, T., & Kanste, O. (2020). Identifying the roles of healthcare leaders in HIT implementation: A scoping review of the quantitative and qualitative evidence. International Journal of Environmental Research and Public Health, 17(8), 1–15. https://doi.org/10.3390/ijerph17082865 

Laukvik, L. B., Rotegård, A. K., Lyngstad, M., Slettebø, Å., & Fossum, M. (2022). Registered nurses’ reasoning process during care planning and documentation in the electronic health records: A concurrent think‐aloud study. Journal of Clinical Nursing, 32(1-2). https://doi.org/10.1111/jocn.16210 

Mashoufi, M., Ayatollahi, H., Khorasani, D., & Talebi, T. (2023). Data quality in health care: Main concepts and assessment methodologies. Methods of Information in Medicine. https://doi.org/10.1055/s-0043-1761500 

Newman, B., Joseph, K., Chauhan, A., Seale, H., Li, J., Manias, E., Walton, M., Mears, S., Jones, B., & Harrison, R. (2021). Do patient engagement interventions work for all patients? A systematic review and realist synthesis of interventions to enhance patient safety. Health Expectations, 24(6), 1905–1923. https://doi.org/10.1111/hex.13343 

NURS FPX 6612 Assessment 3

Russell, C. K., & McNeill, M. (2022). Implementing a care plan system in a community hospital electronic health record. CIN: Computers, Informatics, Nursing, Publish Ahead of Print. https://doi.org/10.1097/cin.0000000000000904 

Solomon, J., Dauber, K., Richardson, S., Levy, S., Khan, S., Coleman, B., Persaud, R., Chelico, J., King, D., Spyropoulos, A., & McGinn, T. (2023). Integrating clinical decision support into electronic health record systems using a novel platform (evidence point): Developmental study. JMIR Formative Research, 7, e44065. https://doi.org/10.2196/44065 

Upadhyay, S., & Hu, H. (2022). A qualitative analysis of the impact of electronic health records (EHR) on healthcare quality and safety: Clinicians’ lived experiences. Health Services Insights, 15(1), 1–7. https://doi.org/10.1177/11786329211070722


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