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NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Student Name

Capella University

NURS-FPX 6612 Health Care Models Used in Care Coordination

Prof. Name


Patient Discharge Care Planning

This assessment focuses on the discharge care planning for Marta Rodriguez, who was recently admitted to the hospital following a severe accident while on her way to college. After a four-week stay in the trauma center, undergoing multiple surgeries, and receiving antibiotic treatment, Marta’s care coordination is essential. In my capacity as the senior care coordinator, I will present Marta’s case during an upcoming interdisciplinary team meeting to discuss her discharge plans.

Longitudinal, Patient-Centered Care Plan

To ensure Marta Rodriguez receives comprehensive, patient-centered care, the interdisciplinary team will employ Health Information Technology (HIT) components to enhance communication and coordination across her care journey. These HIT elements encompass electronic health records (EHRs), secure messaging platforms, telehealth technology, and medication reconciliation tools. EHRs will facilitate real-time access and updates to Marta’s medical records, enabling the development of a comprehensive care plan (Schwab et al., 2021).

Secure messaging platforms will streamline communication among team members, particularly regarding changes in Marta’s condition, appointments, and medication schedules (Flickinger et al., 2022). Telehealth technology will enable remote monitoring of Marta’s vital signs, enabling early intervention (Chowdhury et al., 2020). Additionally, medication reconciliation tools will ensure the accuracy of her medication list, thereby reducing medication errors.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

To prevent Marta’s readmission within 48 hours after discharge, the inter-professional team must ensure Marta receives adequate education, support, and follow-up care (Oksholm et al., 2023). The utilization of HIT elements can bolster these efforts. For instance, telehealth technology can monitor Marta’s post-discharge progress, offer virtual support, and identify potential issues that might lead to readmission. Furthermore, secure messaging platforms can provide Marta with timely and accurate information regarding her medication and follow-up appointments.

Meanwhile, the incorporation of these HIT elements will promote care coordination for Marta by fostering communication and collaboration among team members. Access to uniform information about Marta will enable the development of a comprehensive care plan. Furthermore, EHRs will permit team members to track Marta’s progress, ensuring that she receives appropriate care throughout her recovery. By harnessing HIT elements, the inter-professional team can deliver a patient-centered, coordinated, and effective care plan tailored to Marta’s unique needs.

Data Reporting

Data reporting holds immense significance in the healthcare industry, shaping care coordination, administration, clinical efficiency, and interdisciplinary innovation in treatment. In Marta Rodriguez’s case, data reporting pertaining to her behaviors can enhance the quality of her care and support her recovery in three key ways:

Care Coordination: Data reporting can facilitate care coordination among inter-professional team members by providing a shared understanding of Marta’s condition and progress (Brooks et al., 2020). For instance, data on Marta’s medication adherence, vital signs, and symptoms can be reported through EHRs or secure messaging platforms, enabling effective collaboration in her care management and reducing the risk of complications or readmissions.

Care Management: Data reporting can shape care management by identifying areas where Marta may require additional support or interventions. Information on her pain levels, mobility, and nutritional status, for example, can be reported to the team, allowing them to adjust her care plan as needed to improve its quality and enhance her recovery.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Inter-professional Innovation: Data reporting can drive innovation in inter-professional care by providing insights into Marta’s behaviors and preferences. Data regarding her language preferences or cultural background can be shared with the team, enabling them to tailor their care to her specific needs, thereby promoting patient-centered care and better outcomes.

To ensure data quality, the team should implement data validation protocols, conduct regular audits, and provide training on data entry and reporting best practices. Additionally, the data must be relevant to Marta’s care goals and aligned with evidence-based practices, allowing the team to make informed decisions and provide her with the best possible care.

Client’s Record Influencing Health Outcomes

Patient records play a pivotal role in improving health outcomes. Marta Rodriguez’s case demonstrates how interprofessional teams can leverage Health Information Technology (HIT) to collect, analyze, and share information from client records, ultimately enhancing patient care and outcomes. This discussion explores how data obtained from patient records can positively influence health outcomes and how interprofessional teams can coordinate their efforts using HIT.

HIT enables interprofessional teams to gather and analyze data from client records, offering insights into trends, patterns, and care gaps (Leslie & Paradis, 2018). For instance, Marta’s records can provide valuable information about her medical history, medication regimen, and health status, facilitating the development of a comprehensive care plan tailored to her unique needs. HIT can also help identify potential risks, such as adverse drug reactions or postoperative complications, enabling prompt intervention to prevent negative health outcomes.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Moreover, HIT enhances care coordination among interprofessional team members. By sharing information from client records, team members can collaborate more effectively in managing patient care. Tools like EHRs and secure messaging platforms enable real-time communication, ensuring that all team members are up-to-date with the latest patient information. This reduces the risk of miscommunication and errors, ultimately leading to improved health outcomes for the patient.

Effective coordination of findings among interprofessional team members requires clear communication, a shared care plan, and a willingness to collaborate towards common goals (Rawlinson et al., 2021). HIT tools provide a centralized platform for accessing and sharing information, ensuring that all team members have a comprehensive understanding of the patient’s care needs. This collaborative approach enables the provision of holistic care that addresses all aspects of the patient’s health, resulting in better health outcomes.

Positive health outcomes can be influenced by the use of HIT to collect, analyze, and distribute data from patient records. Interprofessional teams can utilize HIT tools to coordinate their efforts, ensuring access to the latest patient information. Through effective collaboration and the proficient use of HIT tools, these teams can provide patient-centered care that comprehensively addresses all aspects of the patient’s health, leading to improved health outcomes.


Marta Rodriguez’s post-discharge care involves a patient-centered approach characterized by effective coordination. The utilization of HIT elements, including EHRs, telehealth technology, medication reconciliation tools, and secure messaging platforms, will enhance communication and coordination across her care continuum. The significance of data reporting in care coordination, clinical efficiency, and interprofessional innovation is acknowledged by the team, with high-quality data providing insights into Marta’s behaviors and preferences, resulting in improved patient-centered care and outcomes.

Client records serve as a valuable source of data for enhancing health outcomes, and the adept use of HIT assists interprofessional teams in collecting, analyzing, and sharing this information to develop a tailored care plan for Marta. The inter-professional team’s effective collaboration will ensure Marta receives proper education, support, and follow-up care, reducing the risk of readmission within 48 hours after discharge.


Brooks, E. M., Winship, J. M., & Kuzel, A. J. (2020). A “Behind-the-Scenes” look at interprofessional care coordination: How person-centered care in safety-net health system complex care clinics produces better outcomes. International Journal of Integrated Care, 20(2).


Chowdhury, D., Hope, K. D., Arthur, L. C., Weinberger, S. M., Ronai, C., Johnson, J. N., & Snyder, C. S. (2020). Telehealth for pediatric cardiology practitioners in the time of COVID-19. Pediatric Cardiology, 41(6), 1081–1091.

Flickinger, T. E., Waselewski, M., Tabackman, A., Huynh, J., Hodges, J., Otero, K., Schorling, K., Ingersoll, K., Tiouririne, N. A.-D., & Dillingham, R. (2022). Communication between patients, peers, and care providers through a mobile health intervention supporting medication-assisted treatment for opioid use disorder. Patient Education and Counseling.

Leslie, M., & Paradis, E. (2018). Is health information technology improving interprofessional care team communications? An ethnographic study in critical care. Journal of Interprofessional Education & Practice, 10, 1–5.

Oksholm, T., Gissum, K. R., Hunskår, I., Augestad, M. T., Kyte, K., Stensletten, K., Drageset, S., Aarstad, A. K. H., & Ellingsen, S. (2023). The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care—A systematic review. Journal of Advanced Nursing.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P., Peytremann-Bridevaux, I., & Gilles, I. (2021). An overview of reviews on interprofessional collaboration in primary care: Barriers and facilitators. International Journal of Integrated Care, 21(2), 32.

Schwab, P., Mehrjou, A., Parbhoo, S., Celi, L. A., Hetzel, J., Hofer, M., Schölkopf, B., & Bauer, S. (2021). Real-time prediction of COVID-19 related mortality using electronic health records. Nature Communications, 12(1).

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning