Holistic Assessment of the Older Adult
Holistic Assessment of the Older Adult
Healthcare technologies have been instrumental in improving efficacy and efficiency in care delivery. Healthcare technology is particularly useful for ensuring structured assessment, seamless documentation, and easy access to information. Physical assessments remain one of the most challenging areas in technological integration due to the demand for hands-on skills in assessment and interpretation. However, various technologies have been used to facilitate the process and promote communication of the findings. This discussion explores the technologies used in the assessment process and strategies to ensure effective communication without them.
The technologies I have witnessed in care delivery include electronic health records (EHRs). These technologies enable nurses to document and share assessment findings, support structured documentation for focused assessments, and facilitate access to information for all professionals. The systems support structured assessments, which help organize information and ensure thorough assessments. Another technology I have seen utilized is mobile documentation apps, which enable nurses to record data at the bedside, often using tablets to improve efficiency and accuracy (Ehrler et al., 2021). The apps help reduce transcription errors and improve documentation timelines. Some of these apps also include voice-to-text features for oral reporting, enhancing documentation accuracy. Most tablets also feature EHR systems, ensuring easy access to and use of information.
Smart devices have been utilized for a long time to facilitate physical assessments. Devices such as pulse oximeters, smart thermometers, blood pressure cuffs, and cardiac monitors facilitate continuous assessment, data recording, transmission, analysis, and storage, and their integration into electronic health records enables routine updates and alerts for swift action (Hickey et al., 2021). These technologies have streamlined workflow and significantly reduced the workload burden on care providers. Another technology is secure messaging apps. These apps are HIPAA-compliant, allowing nurses and other care professionals to communicate promptly with other care team members, thereby eliminating communication delays (Small et al., 2023). The technologies facilitate written and oral communication and are commonly used in emergency and critical care settings, such as the ICU, theatre, and accident and emergency units, where swift communication and action are crucial for saving lives. The assessment findings, such as a deteriorating neurological or hemodynamic status, are relayed promptly, and corrective action is implemented.
In addition to technology use, various evidence-based strategies have been used to ensure effective communication of assessment findings. The SBAR (Situation, Background, Assessment, Recommendation) structured framework is one of the formats used to ensure effective communication, especially during handoffs, both written and oral. This strategy provides a universal, comprehensive structure that improves clarity and eliminates ambiguity in clinical documentation. Interdisciplinary rounds and verbal briefings are strategies that have withstood the test of time. The strategy utilizes face-to-face communication to promote team collaboration, facilitate collective decision-making, and clarify findings. Standard operating procedure forms are another effective communication tool, often integrated with technology, that can be used without technology to ensure effective communication. SOP forms are used in routine care processes to align care to best practice. Garg (2023) notes that SOPs guide specific conditions and procedures, integrate EBP, and ensure uniformity in care delivery processes.
Healthcare technologies have been instrumental in improving care outcomes. EHRs, secure messaging apps, continuous monitoring devices/smart devices, and mobile apps have been instrumental in the collection, documentation, storage, and transmission of healthcare data. In their absence, strategies such as standard operating procedures, SBAR communication, and standardized terminology can be used to ensure effective communication of assessment findings. These strategies can facilitate and improve data collection and communication during physical assessment.
References
Ehrler, F., Wu, D. T., Ducloux, P., & Blondon, K. (2021). A mobile application to support bedside nurse documentation and care: A time and motion study. JAMIA Open, 4(3), ooab046. https://doi.org/10.1093/jamiaopen/ooab046
Garg, A. (2023). Policies and Standard Operating Procedures (SOP). In Monitoring Tools for Setting up the Hospital Project: Initial Planning, Building and Equipment (pp. 511-613). Singapore: Springer Nature Singapore. https://doi.org/10.1007/978-981-99-6203-7_17
Hickey, B. A., Chalmers, T., Newton, P., Lin, C. T., Sibbritt, D., McLachlan, C. S., Cliftin-Bligh, R., Morley, J., & Lal, S. (2021). Smart devices and wearable technologies to detect and monitor mental health conditions and stress: A systematic review. Sensors, 21(10), 3461. https://doi.org/10.3390/s21103461
Small, W., Iturrate, E., Austrian, J., & Genes, N. (2023). Electronic health record messaging patterns of health care professionals in inpatient medicine. JAMA Network Open, 6(12), e2349136-e2349136. https://doi.org/10.1001/jamanetworkopen.2023.49136
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Discussion Question:
As nurses, we complete physical assessments routinely, even though they are typically focused assessments. What type of technology have you seen utilized in your assessment process that assists in effectively communicating findings both orally and in written format? Without technology, how do you ensure effective communication for assessment findings?