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I currently work in a psychiatric hospital on the acute adult unit. My hypothetical scenario that occurs frequently and requires the acquisition and application of information is an admission to the unit. Upon arrival to the unit, we obtain vital signs, height, weight, and other alphanumeric data (McGonigle & Mastrian, 2018, p. 22). I obtain subjective information from the client and objective information from my perspective during the intake interview.
Frequently our clients have been treated by us on other occasions. In this case, I will also access electronic health records (EHRs) to obtain previous treatment files to determine past medications and diagnoses. I can also access information from hospitalizations at our other campus when needed. This “shared knowledge” allows for continuity of care and reduction of possible errors in treatment (Nagle, Sermeus, & Junger, 2017). Another type of information that would be gathered is a computer-based MMPI (Minnesota Multiphasic Personality Inventory). The MMPI is “…the most frequently used clinical testing instrument and is one of the most researched psychological tests in existence” (Cherry, 2020). Our psychologist uses this data to make diagnostic and treatment recommendations.
The initial admission information is compiled in an easily accessible format so that the other team members can access the information to complete their portions of the new admission paperwork. Unfortunately, my organization still utilizes paper-based charting, which contributes to a great deal of redundancy and wasted time. We hope to move to computer-based charting soon.
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