Soap Note: Bacterial Vaginosis

Week 3 Soap Note: Bacterial Vaginosis

Patient Initials: WJ Age: 22 Gender: Female

SUBJECTIVE DATA:

Chief Complaint: “I have vaginal itching with discharge and foul odor for the past one week ”

History of Present Illness: WJ is a 26-year-old Hispanic American female who presented to the clinic with complaint of vaginal itching with thin, gray vaginal discharge. Patient reported that the vaginal discharge has a strong foul, fishy odor, and the vaginal odor was particularly strong with a fishy smell after sex for the past one week. Patient stated that she has burning on urination, but denied fever, chills, nausea or vomiting. She reported that she decided to see a health care provider because she could not tolerate the odor, burning and discharge anymore.

Location: Vaginal

Duration: One week.

Quality: Itching, gray vaginal discharge; strong foul odor with fishy smell

Radiation: None

Severity: 8/10 on a scale of 1 to 10.

Timing/Onset: One week ago, but worse in the past 2 days.

Alleviating Factors: None

Aggravating Factors: sexual intercourse

Relieving Factors: Sitz bath

Treatments/Therapies: None except warm sitz bath

Medications: None

Allergy: No known drug or food allergy.

Past Medical History: None

Past Surgical History: None

GYN History: LMP 06/09/2016; last Pap smear 05/2016; result: WNL; menarche 12; cycle 5 days; age of first intercourse 18 year; number of partners one; no contraceptive, heterosexual.

OB History: Gravida: 0 Para: 0

Personal/Social History: Single; denied recreational drug/alcohol use. Lives alone. Sexually active.

Immunizations: up to date with vaccination; positive influenza vaccine in November 2015. Negative Pneumococcal vaccine.

Family History: Diabetes: father; hypertension: Mother; both parents still living .

Review of Systems:

General: Patient appeared well nourished; active, denied change in weight .

HEENT: Patient denies headache or head injury, wears contact lenses, denies nasal/sinus congestion or drainage. Denies hearing problem, tinnitus or vertigo. H e reports that he had his dental exam within the last 6 months, and denies any bleeding gums, gingivitis or ulceration lesions; denies chewing or swallowing problem.

Neck: Denies neck pain, tenderness, swelling, or neck injury.

Respiration: Denies difficulty breathing, cough or coughing up blood, or dyspnea at rest .

Cardiovascular: Denies chest pain, SOB, palpitations, edema, arrhythmias, and heart murmur. Gastrointestinal: Denies abdominal pain, nausea, vomiting, or changes in bowel/bladder regularities. Admits good appetite.

Peripheral Vascular: denies any peripheral vascular problem .

Urinary: Reports burning on urination, denies back pain, frequency, blood in the urine.

GYN: Reports vaginal itching with thin, gray vaginal discharge. Reports vaginal discharge with strong foul, fishy odor; reports vaginal odor particularly strong with a fishy smell after sex, denies STDs.

Musculoskeletal: Denies joint pains, joint stiffness, or problem with joints range of motion.

Psychiatry: Denies anxiety, depression, mood changes, and mental health. Denies any suicidal ideation or attempt.

Neurological: Denies memory loss, dizziness, tingling/numbness, falls, and seizures.

Integument/Hematology/Lymph: Denies bruising easilyskin rashes, dryness, itching, skin lesions and cancer. Denies any clotting or bleeding disorders. Denies transfusion reaction.

Endocrine: Denies diabetes, thyroid problem, heat or cold intolerance.

Allergic/Immunologic: Denies allergic rhinitis, denies immune deficiencies.

OBJECTIVE DATA

Physical Exam:

General: Alert and oriented. Appeared well-groomed. Patient does not appeared to be in any acute distress. Vital signs: B/P 116/74, left arm, sitting; P 76; RR 18; SPO2 100% RA. Weight 132 pounds, BMI 20.53, Height 65 inches.

HEAD: Head round and symmetry, no lesions, bumps, nodules, or injury noted.

EENT: PERRLA, clear conjunctiva and sclera; hearing intact bilateral; TMs visualized, pearly grey; clear nasal passage, normal turbinates, septal deviation absent. Oral mucosa pink and moist .

Neck: thyroid supple, midline trachea, no thyromegaly or lymphadenopathy

Chest/Lungs: Chest wall symmetrical, no use of accessory muscles note, breath sound are clear to auscultation, no wheezing, rhonchi, or prolonged expiration noted in the upper/lower lung fields. No nipple discharges or abnormal lump noted.

Heart: S1, S2 noted with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs noted. Capillary refill normal at 2 seconds. Pulses palpable/normal at 2+. No edema noted.

Abdomen: Abdomen is soft, non-tender and non-distended. Bowels sounds are present in all 4 quadrants. No hepatosplenomegaly.

Genital: Gray, thin, watering vaginal discharge with foul fishy odor noted.

Musculoskeletal: Full range of motion present in all extremities. No varicose vein, clubbing, cyanosis, or edema present. Palpable peripheral pulses present .

Neurologic: Alert and oriented; ambulatory with steady gait. Speech clear/audible. All extremities movable. Touch sensation and two- point discrimination present and intact .

Skin: No rashes, nodes, lumps, ulcers noted. Skin moisture good and turgor is intact.

ASSESSMENT:

Lab Test and Results:

Urine dipstick: Negative

Pelvic/Vaginal examination: showed gray thin watering discharge with foul, fish odor, vaginal swab obtained for microscopic examination, such as

wet mount test; whiff test; vaginal pH test, and oligonucleotide probes test (send out test).

Swap applied to wet mount for whiff amine test, clue cells test, and applied to litmus paper to check for pH. Results: KOH positive for fishy odor; pH 5.2; wet mount: clue cells present

Differential Diagnosis :

1. Bacterial Vaginosis

2. Vaginal Candidiasis

3. Trichomoniasis

Primary Diagnosis:

Bacterial vaginosis (BV): is the primary diagnosisWomen’s Health (WH, 2015) describe bacterial vaginosis as the vaginal infection that results from overgrowth of bacterial usually found in the vagina which disrupt the natural balance. Bacterial vaginosis can affect women of any age, but usually affect women in their reproductive years. According to WH (2015) signs and symptoms include vaginal discharge that is white or milky or gray in color. Also, the discharge can be watery or foamy with strong fishy odor usually after sex; itchy, irritating vagina, and burning on urination. Moreover, WH (2015) explained that diagnosis are made based on vaginal exam, results of swap vagina fluid obtained during physical examination, such as wet mount test; whiff test; vaginal pH test, and oligonucleotide probes test results. Diagnosis can be made based on the result of three out of the four tests according to WH (2015). The rationales for identifying bacterial vaginosis as the primary diagnosis are that patient’s pelvic/vaginal examination revealed thin, watery, grey discharge. Also, laboratory test for wet mount test; whiff test; vaginal pH test are all positive, and when these tests are positive with the vaginal discharge that is synonymous with bacterial vaginosis, the diagnosis of bacterial vaginosis is established.

Vaginal Candidiasis: Commonly known as yeast infection. The infection is caused by fungus candida, which causes extreme itching, swelling, and irritation. Symptoms include rash, vaginal discharge that is usually thick, white, and odorless; itching, burning, pain during sex, soreness, and burning. Vaginal candidiasis is ruled out as the primary diagnosis because of the difference in the vaginal discharge, which is odorless, thick, and white like cottage cheese unlike bacterial vaginosis (Center for Disease Control and Prevention [CDC], 2016).

Trichomoniasis: The CDC (2016) explained that trichomoniasis is a sexual transmitted disease. the infection is caused by protozoan parasite known as trichomonas vaginalis. The infection is transmitted from an infected person to an uninfected person during sex. In addition, CDC (2016) explained that the signs and symptoms trichomoniasis to include mild irritation to severe inflammation, burning, itching, redness or soreness genitals; discharge can be thin, frosty, greenish, yellowish, clear or white with unusual smell. The CDC (2016) stipulated that trichomoniasis cannot be diagnosed based on symptoms alone. Laboratory test or check is needed to diagnose the infection. Trichomoniasis is ruled out as the possible differential diagnosis because the patient discharge is not frosty, yellow-green.

PLAN:

Diagnostic plan: Oligonucleotide probes test will be ordered and send out to outside diagnostic lab company. Wet mount test, KOH/whiff test, and litmus test for pH were all ordered and tested. Results: positive.

Treatment and Management:

Bacterial vaginosis resolved spontaneously for most women, but the patient has been having the symptoms for one week. I will use an antibiotic therapy.

Antibiotics Therapy:

Metronidazole (Flagyl), 500 mg orally twice daily for seven days .

Alternative Therapy

I will recommend probiotics, such as Lactobacillus acidophilus, which will help eliminate high levels of bad bacteria and replace them with good bacteria. The rationale is that acidophilus is a known good bacteria. Also, I will recommend apple cider vinegar; the rationale is that bacterial vaginosis is caused be change in vaginal pH. The apple cider vinegar is natural acidic compound and will help regulate the patient body pH and naturally restore pH balance (Machado, Castro, Palmeira-de-Oliveira, Martinez-de-Oliveira, & Cerca, 2015). In addition, I will recommend hydrogen peroxide because hydrogen peroxide is natural disinfecting agent, and patient will be directed to insert tampon soaked with 3% hydrogen peroxide purchased at drugstore, the goal is to eliminate bad bacteria in the patient body (Machado et al., 2015).

Nonpharmacological Treatment:

Yogurt will be recommended to the patient, and patient advised to eat two cups of plain yogurt daily. Rationale is to restore normal pH balance in the vagina inhibiting the growth of bad bacteria. Moreover, tea tree oil will be recommended to the patient, and patient will be instructed to add few drops of tea tree oil in warm water, stir the water and use the water to rinse vaginal daily for three to 4 weeks (Machado et al., 2015). The rationale is to kill the bacteria that cause bacterial vaginosis as well as eliminate the foul fishy odor associated with bacterial vaginosis because tea tree oil has both natural antibacterial and antifungal compounds. Furthermore, patient will instructed to eat raw or cooked garlic daily because the garlic natural antibiotic properties. The rationale is to keep the eliminate bad bacterial (Machado et al., 2015).

Health Promotion:

Patient will be educated to wipe from front to back instead of back to front to void contaminating the vagina with bacterial from the rectum. Also, patient will be educated to keep her vulva clean and dry. In addition, patient will be educated to refrain from using agents that are irritating in her vagina, such as strong soaps, feminine hygiene sprays, or douching. Furthermore, patient will be educated to abstain from tight jeans, panty hose with no cotton crotch, or clothing that trap moisture. Have only single sex partner and use condom (Public Health, 2015).

Reflection Note and Follow-Up

What I will do differently on a similar patient evaluation is that I will check the patient hemoglobin A1C to rule out diabetic origin of the condition . I would send the patient home to try the recommended home remedies for few days and come back for antibiotic treatment since bacterial vaginosis can be resolved without treatment to prevent antibiotic resistance. Patient will be schedule to follow-up in 14 days to repeat the diagnostic test to make sure that the infection is cleared, and if the infection is not cleared, I will repeat antibiotic treatment. I agree with my preceptor diagnosis based on the available positive test results and clinical guidelines .

References

Centers for Disease Control and Prevention. (2016). Genital/vulvovaginal candidiasis.

Retrieved from http://www.cdc.gov/fungal/diseases/candidiasis/genital/index.html

Centers for Disease Control and Prevention. (2016). Trichomoniasis. Retrieved from

http://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm

Machado, M., Castro, J., Palmeira-de-Oliveira, A., Martinez-de-Oliveira, J., & Cerca, N.

(2015). Bacterial vaginosis biofilms: Challenges to current therapies and emerging solution. Front Microbiol, 6, 1528-1542. doi: 10.3389/fmicb.2015.01528

Public Health. Bacterial vaginosis: Women’s health guide. Retrieved from

http://www.publichealth.va.gov/infectiondontpassiton/womens-health-

guide/bacterial-vaginosis.asp

Women’s Health. (2015). Bacteria vaginosis. Retrieved from

http://womenshealth.gov/publications/our-publications/fact-sheet/bacterial-

vaginosis.html

SOAP note rubric

Subjective (15 points) Points Possible Points Earned
· CC 1 1
· Pertinent positives (OLDCARTS) 5 5
· Pertinent negatives & positives (from ROS) 5 4
· Pertinent PMH, SH, and FH 3 3
· Medications and drug/food allergies are included 1 1
Objective (15 points)
· VS including FHT if indicated 3 3
· Thyroid, Heart, and Lungs 1 1
· Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. -5 1
· Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. -5 5
· Diagnostic test results (ex; BHCG, CBC, Rubella, RPR, pap, GC, CT, 1 HR GTT, GC/CT, urine dip, wet prep, Blood group & RH Status) 2 2
Assessment (10 points for each priority diagnosis to equal 30) 30 30
Plan (15 points)
· Medications discontinued (“d/c lisinopril 10 mg daily”) 1 NA/1
· Medications started (“start Ferrous Sulfate 325 mg daily”) 2 2
· Alternative therapies if appropriate (1 point) 1 NA/1
· Diagnostic tests ordered with timeframe 6 6
· Referrals or consultations if appropriate 2 2
· Follow-up interval 3 3
Reflection notes (25 points)
· What did you learn from this experience? Any ah-ha’s? (5 points) 5 0
· What would you do differently? 5 5
· What additional data would you have gathered? 5 5
· What additional elements of the exam would you have done? 5 0
· Do you agree with your preceptor based on the evidence? 5 5
Total points 100 85

Overall great work on your first SOAP note, please see comments.

�Great CC, clear concise in patient’s own words.

�Great use of OLDCARTS

�Great history

�Any fever, chills, fatigue?

�She

�Unnecessary

�Unnecessary

�Unnecessary in this case

�Unnecessary in this case

�Unnecessary in this case

�Unnecessary in this case

�Great

�Great choice, first line treatment for BV

�This may be beneficial in recurrent cases however besides fam hx, patient does not have any other risk factors, young, normal BMI.

�In The reflections you are to list What did you learn from this experience? Not addressed.

What would you do differently? You addressed this.

What additional data would you have gathered? You addressed this.

What additional elements of the exam would you have done? Not addressed

Do you agree with your preceptor? You addressed this.

See SOAP note template, even if you don’t have anything to add, just state that with the question.

Family Focused Assessment

Develop an interview questionnaire to be used in a family-focused functional assessment. The questionnaire must include three open-ended, family-focused questions to assess functional health patterns for each of the following:

  1. Values/Health Perception
  2. Nutrition
  3. Sleep/Rest
  4. Elimination
  5. Activity/Exercise
  6. Cognitive
  7. Sensory-Perception
  8. Self-Perception
  9. Role Relationship
  10. Sexuality
  11. Coping

Select a family, other than your own, and seek permission from the family to conduct an interview. Utilize the interview questions complied in your interview questionnaire to conduct a family-focused functional assessment. Document the responses as you conduct the interview.

Upon completion of the interview, write a 1000- 1250 word paper. Analyze your assessment findings. Submit your questionnaire as an appendix with your assignment.

Include the following in your paper:

  1. Describe the family structure. Include individuals and any relevant attributes defining the family composition, race/ethnicity, social class, spirituality, and environment.
  2. Summarize the overall health behaviors of the family. Describe the current health of the family.
  3. Based on your findings, describe at least two of the functional health pattern strengths noted in the findings. Discuss three areas in which health problems or barriers to health were identified.
  4. Describe how family systems theory can be applied to solicit changes in family members that, in turn, initiate positive changes to the overall family functions over time.

Cite at least three peer-reviewed or scholarly sources to complete this assignment. Sources should be published within the last 5 years and appropriate for the assignment criteria.

Prepare this assignment according to the APA , NO PLAGIARISM PLEASE

Managed Care Organizations (MCOs) Vs. Accountable Care Organizations (ACOs)

Discuss the differences and similarities between Managed Care Organizations (MCOs) vs. Accountable Care Organizations (ACOs). Given the current health care environment, provide a solid speculation to how MCOs and ACOs may transform to meet the needs of its consumers. Be sure to support your thoughts and analysis with scholarly sources.

Case Study On Death And Dying

The practice of health care providers at all levels brings you into contact with people from a variety of faiths. This calls for knowledge and understanding of a diversity of faith expressions; for the purpose of this course, the focus will be on the Christian worldview.

Based on “Case Study: End of Life Decisions,” the Christian worldview, and the worldview questions presented in the required topic study materials you will complete an ethical analysis of George’s situation and his decision from the perspective of the Christian worldview.

Provide a 1,500-2,000-word ethical analysis while answering the following questions:

  1. How would George interpret his suffering in light of the Christian narrative, with an emphasis on the fallenness of the world?
  2. How would  George interpret his suffering in light of the Christian narrative, with an emphasis on the hope of resurrection?
  3. As George contemplates life with amyotrophic lateral sclerosis (ALS), how would the Christian worldview inform his view about the value of his life as a person?
  4. What sorts of values and considerations would the Christian worldview focus on in deliberating about whether or not George should opt for euthanasia?
  5. Given the above, what options would be morally justified in the Christian worldview for George and why?
  6. Based on your worldview, what decision would you make if you were in George’s situation?

Remember to support your responses with the topic study materials.

Prepare this assignment according to the guidelines found in the APA Style Guide. An abstract is required.

This assignment uses a rubric.You are required to submit this assignment to LopesWrite.

1. Bioethics: A Primer for Christians

Read Chapters 6 and 12 in Bioethics: A Primer for Christians.

http://gcumedia.com/digital-resources/wm-b-eerdmans-publishing-co/2013/bioethics_a-primer-for-christians_ebook_3e.php
2. Called to Care: A Christian Worldview for Nursing

Read Chapters 10-12 in Called to Care: A Christian Worldview for Nursing.

http://gcumedia.com/digital-resources/intervarsity-press/2006/called-to-care_a-christian-worldview-for-nursing_ebook_2e.php

3. Defining Death: Medical, Legal and Ethical Issues in the Determination of Death

Read the Introduction and Chapters 1-3 of “Defining Death: Medical, Legal and Ethical Issues in the Determination of Death” by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1984).

https://repository.library.georgetown.edu/bitstream/handle/10822/559345/defining_death.pdf?sequence=1

Rubric

  1. Analysis of how the man would interpret his suffering in light of the Christian narrative and the fallenness of the world is clear and demonstrates a deep understanding that is skillfully supported by topic study materials. 12%
  2. Analysis of how the man would interpret his suffering in light of the Christian narrative and the hope of resurrection is clear and demonstrates a deep understanding that is skillfully supported by topic study materials. 12%
  3. Analysis of how the Christian worldview of the man might inform his view about the value of his life as a person with ALS is clear and demonstrates a deep understanding that is skillfully supported by topic study materials.12%
  4. Evaluation of which values and considerations the Christian worldview focuses on when deliberating the option of euthanasia for the man is clear and demonstrates a deep understanding that is skillfully supported by topic study materials. 12%
  5. Evaluation of which options would be justified in the Christian worldview for the man is clear and demonstrates a deep understanding that is skillfully supported by topic study materials. 12%
  6. Reflection hypothesis of which personal choices would be make if faced with ALS based on personal worldview is clear, relevant, and insightful. 10%
  7. Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear. 7%
  8. Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative. 8%
  9. Writer is clearly in command of standard, written, academic English. 5%
  10. All format elements are correct.5%
  11. Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. 5%

The Systems Development Life Cycle and the Nurse Informatics

Discussion: The Systems Development Life Cycle and the Nurse Informaticist

 

 

 

The systems development life cycle (SDLC) is a model for planning and implementing change within an organization. It is important for many individuals to be represented in the process, especially the end users of the system or the employees who must live with the change. As informatics become more and more widespread throughout the health care field, collaboration between information technology (IT) professionals and health care practitioners is becoming increasingly important. The nurse informaticist is able to combine the perspective of the information technology side with the clinical nursing perspective.

 

While the titles and specific responsibilities of nurse informaticists vary across organizations and practice settings, the fundamental purpose of the role remains the same. Nurse informaticists synthesize their knowledge of how technology can improve health care with an understanding of clinical practice and workflow. This is why nurse informaticists can be instrumental in facilitating the SDLC for informatics in health care. For this Discussion, you examine the relationship between the nurse informaticist and the use of the SDLC.

 

 

 

To prepare:

 

  • Review the information in this week’s Learning Resources on the SDLC and the role of the nurse informaticist. Reflect on Chapter 1 of the Dennis, Wixom, and Roth course text and consider how the information about the systems analyst role translates into nursing and health care.
  • Consider a recent change in your organization related to the implementation of a new technology or system. How was this change handled? What was the general SDLC process? Who was involved, and what were the outcomes?
  • Identify whether your organization (or one with which you are familiar) has a formal title or position for the nurse informaticist. This position may be called by a different name, such as nurse informatics specialist or informatics analyst, so be sure to review the position description.
  • If your organization has a position for the nurse informaticist, what are the responsibilities of that position? If your organization does not have such a position, conduct research in the Walden Library and at credible online sources on the role of the nurse informaticist.
  • Reflect on the role of the nurse informaticist in the overall health care field. How is this position connected to the SDLC? Assess the benefits of having this specialized position within health care organizations and involving the nurse informaticist in the SDLC.

     

     

    Post by tomorrow 8/30/16 550 words in APA format with a minimum of 3 references from the list provided under Required Readings. Apply the level 1 headings as numbered below:

    1) A description of how the systems development life cycle is utilized in your organization (Hospital), or in one with which you are familiar, and assess its effectiveness.

     

    2)  Assess the role of the nurse informaticist in your organization. If the nurse informaticist is not a current position within your organization, provide a description of the generally accepted role of the nurse informaticist based on this week’s Learning Resources and your own research.

     

    3)  Explain why it is important for the nurse informaticist to be involved in the SDLC process and the overall organizational benefits of having such involvement.

     

     

     

     

    Required Readings

     

    Dennis, A., Wixom, B. H., & Roth, R. M. (2015). Systems analysis and design (6th ed.). Hoboken, NJ: Wiley.

 

  • Chapter 1, “The Systems Analyst and Information Systems Development” (pp. 1–34)

 

In this chapter, the authors clarify the relationship between systems analysts and information systems development. The chapter also covers the basic business applications of information systems.

 

 

 

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

 

  • Chapter 10, “Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making”

 

 

 

  • Chapter 11, “Administrative Information Systems”

 

Quality, organizational decision making is a requisite to successful advancements in technology. This chapter explores how workplaces respond to the necessity for improved information systems.

 

 

 

 

 

Anderson, C., & Sensmeier, J. (2011). Nursing informatics scope of practice expands, salaries increase. Computers, Informatics, Nursing, 29(5), 319–320.

 

Retrieved from the Walden Library databases.

 

This article assesses the growing need for informaticists in the health care industry. The combination of clinical and information technology experience that informaticists possess makes them invaluable in assisting in the health care industry’s transition into a heavier use of information systems.

 

 

 

Houston, S. M. (2012). Nursing’s role in IT projects. Nursing Management, 43(1), 18–19.

 

Retrieved from the Walden Library databases.

 

The societal advancements of information technology (IT) are major factors in the governance of health care organizations. This article gives an overview of how nurse informaticists blend their clinical know-how with IT to improve workflow and patient care.

 

 

 

McLane, S., & Turley, J. P. (2011). Informaticians: How they may benefit your healthcare organization. The Journal of Nursing Administration, 41(1), 29–35.

 

Retrieved from the Walden Library databases.

 

Nursing informaticists help guide the implementation of information systems into health care organizations. The authors of this article evaluate how informaticists effect change in management and improve meaningful use in nursing practice.

 

Prestigiacomo, J. (2012). The rise of the senior nurse informaticist. Healthcare Informatics, 29(2), 38–43.

 

Retrieved from the Walden Library databases.

 

The author of this article highlights the conditions of the health care industry and its growing reliance on data-driven decision making. Nurse informaticists are important in this transition, playing a major role in the development and utilization of electronic health records (EHRs).

 

Warm, D., & Thomas, B. (2011). A review of the effectiveness of the clinical informaticist role. Nursing Standard, 25(44), 35–38.

 

Retrieved from the Walden Library databases.

 

Health care organizations rely heavily on information management and technology for organizational maintenance and patient care. This article examines the clinical informaticist’s role in facilitating the implementation of health information technology and spearheading clinical risk management.