NURS-FPX4040 Assessment 1: Nursing Informatics In Health Care

Assessment 1: Nursing Informatics in Health Care

To: The Chief Nursing Officer

CC: Human Resources Manager

REF: Creating the Position of a Nurse Informaticist in the Organization

Health care delivery has evolved into a technology-driven practice as nursing organizations and professionals strive to achieve high-quality care. The essentials of such care include healthy patient-provider interactions, timely communication, and accurate data. In nursing, using various technologies, including electronic health records, mobile apps, and patient portals, can only be maximized with robust information technology systems. Qualified professionals who help such systems work and integrate the relevant health information technology (IT) into patient care are critical for health care facilities. Therefore, this proposal aims to recommend the role of a nurse informaticist in this organization.

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Nursing Informatics and the Nurse Informaticist

Nursing comprises multiple specialties with varying roles to ensure care that meets the current patient’s needs. According to Garcia-Dia (2021), the American Nurses Association (ANA) formalized nursing informatics in 1992, followed by its expansion in various forms and functions. Largely, the specialty involves integrating nursing, computer, and informational sciences into health care delivery to enhance patient outcomes. Its purpose is to support nursing evolution through data and systems, enabling providers to offer data-driven and technology-based care. Therefore, organizations seeking to evolve as times necessitate should value nursing informatics and support it accordingly.

Understanding the role of a nurse informaticist is essential for informed decision-making as far as its creation is concerned. In routine practice, nurse informaticists specialize in using data and technologies to monitor patient care, health care programs, and electronic systems. Their high-level information and technology skills enable them to assess processes from scientific, analytical, and clinical dimensions to determine effectiveness and areas of capacity improvement (Huber & Joseph, 2021). Other valuable roles of a nurse informaticist include researching the need for new technologies and guiding health care facilities in their development and implementation. These functions depict a nurse informaticist as a professional handling a highly technical role that all health care organizations should consider for effective utilization and management of health IT.

Nurse Informaticists and Other Health Care Organizations

To validate the need for a nurse informaticist in this organization, it is crucial to evaluate how other facilities have experienced the role. Due to the increased need for technology use after the COVID-19 outbreak, the role of nursing informatics in the current practice has become vivid. Sadasivaiah et al. (2021) explained the benefits of health IT and informatics response to the pandemic across the San Francisco Department of Public Health (SFDPH) care network after California declared a state of emergency after the outbreak. Through informatics, the network comprising rehabilitation hospitals, primary care, trauma center, skilled nursing and other facilities was able to cooperate, expand testing capacity and meet the needs of vulnerable populations. Other opportunities realized through informatics response included expanded public health analytics and improved research capacity across SFDPH (Sadasivaiah et al., 2021). The positive experiences of these health care organizations during a crisis underscore the need for specialists to guide care facilities in adopting and maximizing the use of health IT.

The promise of nursing informatics in care delivery can only be achieved with effective interprofessional collaboration. Hence, nurse informaticists interact with other nursing staff and the interdisciplinary team to ensure the safe and efficient use of health technologies, systems, and data. Routinely, nursing staff members consult the nurse informaticist on matters concerning electronic health systems. The interdisciplinary team also collaborates with nurse informaticists to analyze patient trends based on data and design effective interventions. The collaboration also empowers health care organizations to embrace and support virtual care for remote patient monitoring.

Nursing Informatics in Health Care

Nurse informatics (NI) is a specialty which entails blending and integrating nursing, computer and information sciences to manage and transfer information and attain insights using data in nursing. The history of health information management indicates that professional organizations like the American Nurses Association (ANA) started recognizing the significance of nursing informatics as a specialty in 1992 (Ye, 2020). Nurses who integrate the specialty into their regular practice become nurse informaticists. By employing a nurse informaticist, an institution can benefit from the skills, knowledge and expertise that such specialized health care provider bring on board that include increased staff morale and patient satisfaction as a result of improved safety and quality care provision. As such, this paper presents a proposal on the need to hire nurse informaticist to the chief nursing officer and the human resource (HR) manager at the institution.

Nurse Informatics and the Nurse Informaticist

Nursing informatics entails the incorporation of information sciences and computer sciences into nursing with the aim of developing and maintaining data and systems that support the nursing practice and assists in enhancing patient outcomes. Different health care technologies have emerged due to nursing informatics that include the deployment and use of electronic health records (EHRs) and the computerized provider order entry (CPOE) (Ye, 2020). Nursing informatics empowers healthcare practitioner to attain patient-centered care and promote health of individuals, families and communities Collins et al., 2017). The implication is that nursing informatics allows health care providers to make better and effective care decisions focused on enhancing patient care and management in different settings.  

Nurse informaticists are medical practitioners who combine their skills in nursing with the deployment of informatics to create systems that can lead to improved patient care and quality outcomes. by using data collected from different medical systems, nurse informaticists can analyze trends, implement changing systems and monitor any errors in a system (Kleib & Nagle, 2018). Nurse informaticists have different roles and responsibilities that they undertake in their line of duty like managing projects, analyzing clinical data, writing policies and monitoring either success or failure of any technological applications in their systems as well as performance of different health car models or interventions that are technologically-dependent.

Nurse informaticists also design systems technology, analyze and assess technology needs of an organization, test system’s technology before their introduction and their implementation. Nurse informaticists also train the staff on the effective use of new technology, troubleshooting and escalation of issues as needed in a healthcare setting. Nurse informaticists also assist in health care organization’s transition from one technology system to another apart from evaluating the overall success of such implementation. Nurse informaticists are also responsible for ensuring that the health care organization meets legal requirements on technology through acts like Health Insurance Portability and Accountability Act (HIPAA).

Nurse Informaticists and Other Health Care Organizations

Nurse informatcists have the capability to impact the health of patients and health care organizations in different ways because of the benefits that they provide to these entities. These benefits include enhanced patient safety and integrity of patient data through effective implementation of medical devices’ initiatives. Nurse informaticists are at the frontline in assisting healthcare organization digitize their manual processes and procedures which leads to saving costs in terms of time and financial resources for these entities.

Nurses informatics also help organizations to enhance their practice as they promote effective ways of information sharing and protection. Through this intervention, health care organizations attain success from implementing evidence-based practice interventions for better and quality patient outcomes. Nurse informaticists continue to help healthcare establishments to enhance patient satisfaction (Collins et al., 2017). For instance, through the implementation of electronic health records system and electronic medical records in such organizations, nurse informaticists have enabled patients to enhance access to their health data and history as well as recommendations which ensures that they improve overall patient outcomes.

Accordingly, health informaticists like nurses are at the center of interdisciplinary collaborations in healthcare organizations. Continued specialization in health care has necessitated increased need for specialized care provision and thus the need for specialists like nurse informaticists when handling major medical issues that require interdisciplinary collaborations (Ye, 2020). The rise in specialists leads to an emerging and more need for better coordination among them to ascertain best quality care to patients. Nurse informaticists promote interdisciplinary collaborations by developing technological solutions that address the coordination matters across inter-professional teams. Nurse informaticists also promote interdisciplinary collaboration through effective leadership practices and followership in various situations as they emerge.

Effects of Nurse Engagement in Healthcare Technology

There is also a guarantee in the protection of health information of a patient through use of technology because of effective documentation that leads to improved workflow in the healthcare provision process. A critical aspect of the workflow efficiency is a projected reduction in medical errors. Health informatics allow organizations and providers to avoid medical errors because they have sufficient data and can make effective decisions

The full engagement of nurse informatics staff using healthcare technology can improve patient care by enhancing communication and help ease the workflow. For instance, physicians and nurses need to communicate with each other to solve patient issues that require multiple input from a multidisciplinary team for successful resolution. With novel communication technologies, inter-professional staff separated by physical location and time must depend on a host of new applications to share information about patients as opposed to face-to-face conversations. Such technologies improve patient participation in healthcare process and empowers them to take active roles to enhance their health. Patients can access information and interact more easily with their care providers which improves their chances of attaining better outcomes (Kleib & Nagle, 2018). Nurse informaticists assist in the coordination of essential information that leads to better outcomes. 

Opportunities and Challenges

By collaborating, the interdisciplinary team can enhance quality care through having discussions on certain needs of each department and seeking the nurse informaticists help to facilitate a process that works for all involved personnel in the facility. Opportunities available based on the role of informatics nurse implementation include better and consistent communication within departments and the facility as well as others, streamlined processes that will enhance workflow and lead to better patients’ outcomes and possibility of enhanced reimbursement (Ye, 2020).

Conversely, challenges may include nurses experiencing frustrations with the new organizational changes since many individuals in organizations fear change. In this case, the implementation of new technologies that they are not familiar with may require more education and deployment of an effective change model for effective roll out.

Summary of Recommendations

Nurse informaticist plays an essential role in any healthcare organization, especially with the increasing reforms and use of medical and health technology. Any organization that seeks to offer high quality care to its patients need to embrace informatics and have nurse informaticists. These health care providers use technology to enhance accuracy, efficiency and confidentiality while protecting patient information (Kleib & Nagle, 2018). The use of nurse informatics is associated with a reduction in adverse events, improved work environment and quality outcomes, reduced length of hospital stays, especially for the aged and critically ill or those with chronic conditions. Technology is a significant part of healthcare and a nurse informaticist is required to ensure that the organization uses all it possess to provide quality care to patients.

Conclusion

An effective and efficient healthcare organization offers exceptional care, focuses on prevention of medical errors and maintains a better and protected patient information database that allows it to maintain better relationships with staff, technology and super users. The implication is that no such entity exists without rollout of costly programs tailored to attain better goals. Having nurse informaticists is the cost-efficient and effective measure to tackle these concerns due to their expertise and nursing knowledge. Therefore, the facility should implement the proposal and employ nurse informaticists.

References

Collins, S., Yen, P. Y., Phillips, A., & Kennedy, M. K. (2017). Nursing informatics competency

assessment for the nurse leader: The Delphi study. JONA: The Journal of Nursing Administration, 47(4), 212-218. doi: 10.1097/NNA.0000000000000467.

Kleib, M., & Nagle, L. (2018). Factors associated with Canadian nurses’ informatics

competency. CIN: Computers, Informatics, Nursing, 36(8), 406-415. doi: 10.1097/CIN.0000000000000434.

Ye, J. (2020). The role of health technology and informatics in a global public health emergency:

practices and implications from the COVID-19 pandemic. JMIR Medical Informatics, 8(7), e19866. doi:10.2196/19866

Write a 4-5 page evidence-based proposal to support the need for a nurse informaticist in an organization who would focus on improving health care outcomes.

Introduction

As you begin to prepare this assessment, you are encouraged to complete the Team Perspectives of the Nurse Informaticist activity. Completion of this will help you succeed with the assessment as you explore the nurse informaticist’s role from the different perspectives of the health care team. Completing activities is also a way to demonstrate engagement.

Nurses at the baccalaureate level in all practice areas are involved in nursing informatics through interaction with information management and patient care technologies. Nurses must not only demonstrate knowledge of and skills in health information and patient care technologies, but also how to use these tools at the bedside and organizational levels. Moreover, nurses need to recognize how information gathered from various health information sources can impact decision making at the national and state regulatory levels.

Scenario

For this assessment, assume you are a nurse attending a meeting of your state’s nurses association. A nurse informaticist conducted a presentation on her role and its impact on positive patient and organizational outcomes in her workplace. You realize that your organization is undergoing many technological changes. You believe this type of role could provide many benefits to your organization.

You decide to pursue proposing a nurse informaticist role in your organization. You speak to your chief nursing officer (CNO) and human resources (HR) manager, who ask you to prepare a 4–5 page evidence-based proposal to support the new role. In this way, they can make an informed decision as to whether the addition of such a role could justify the return on investment (ROI). They need your proposal before an upcoming fiscal meeting.​ This is not an essay, but instead, it is a proposal to create a new Nurse Informaticist position.

One important part of this assessment is the justification of the need for a nurse informaticist in a health care organization and references from relevant and timely scholarly or professional resources to support the justification for creating this nurse informaticist position. The term justify means to show or prove that the nurse informaticist position brings value to the organization. This justification must include evidence from the literature to support that this position will provide a return on investment for the organization.

Preparation

To successfully prepare for this assessment, you will need to complete these preparatory activities:

  • Review assessment resources and activities.
    • Conduct independent research on the nursing knowledge and skills necessary to interact with health information and patient care technology.
    • Focus your research on current resources available through peer-reviewed articles, professional websites, government websites, professional blogs, wikis, job boards, and so on.
  • Consult the BSN Program Library Research Guide for help in identifying scholarly and authoritative sources.
  • Interview peers in your network who are considered information technology experts.
    • Ask them about how information technology advances are impacting patient care at the bedside, at the organizational level, and beyond.

Proposal Format

The chief nursing officer (CNO) and human resources (HR) manager have asked you to include the following headings in your proposal and to be sure to address the bullets following each heading:

Nursing Informatics and the Nurse Informaticist
  • What is nursing informatics?
  • What is the role of the nurse informaticist?
Nurse Informaticists and Other Health Care Organizations
  • What is the experience of other health care organizations with nurse informaticists?
  • How do these nurse informaticists interact with the rest of the nursing staff and the interdisciplinary team?

Impact of Full Nurse Engagement in Health Care Technology

  • How does fully engaging nurses in health care technology impact:
    • Patient care?
    • Protected health information (security, privacy, and confidentiality)?
      • In this section, you will explain evidence-based strategies that the nurse informaticist and interdisciplinary team can use to effectively manage patients’ protected health information, particularly privacy, security, and confidentiality. Evidence-based means that they are supported by evidence from scholarly sources.
    • Workflow?
    • Costs and return on investment?
Opportunities and Challenges
  • What are the opportunities and challenges for nurses and the interdisciplinary team with the addition of a nurse informaticist role?
    • How can the interdisciplinary team collaborate to improve quality care outcomes through technology?
Summary of Recommendations
  • What are 3–4 key takeaways from your proposal about the recommended nurse informaticist role that you want the CNO and the HR manager to remember?
    • This is the section where the justification for the implementation of the nursing informaticist role is addressed. Remember to include evidence from the literature to support your recommendation.
Additional Requirements
  • Written communication: Ensure written communication is free of errors that detract from the overall message.
  • Submission length: 4–5 double-spaced pages, in addition to title and references pages.
  • Font: Times New Roman, 12 point.
  • Citations and References: Cite a minimum of three current scholarly and/or authoritative sources to support your ideas. In addition, cite a minimum of one current professional blog or website to support your central ideas. Current means no more than five years old.
  • APA formatting: Be sure to follow APA formatting and style guidelines for citations and references. For an APA refresher, consult the Evidence and APA page on Campus.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

  • Competency 1: Describe nurses’ and the interdisciplinary team’s role in informatics with a focus on electronic health information and patient care technology to support decision making.
    • Define nursing informatics and the role of the nurse informaticist.
    • Explain how the nurse collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care.
    • Justify the need for a nurse informaticist in a health care organization.
  • Competency 2: Implement evidence-based strategies to effectively manage protected health information.
    • Explain evidence-based strategies that the nurse and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality).
  • Competency 5: Apply professional, scholarly communication to facilitate use of health information and patient care technologies.
    • Follow APA style and formatting guidelines for citations and references.
    • Create a clear, well-organized, and professional proposal that is generally free from errors in grammar, punctuation, and spelling.

Nursing Informatics in Health Care

Nursing informatics is a relatively young area that focuses on the management and communication of information and knowledge in nursing practice for the purpose of improving the quality of care provided to patients as well as nurses and other medical professionals. In the field of nursing informatics, nursing science is merged with other information sciences such as computer science and other information sciences. According to the Global Journal of Health Science, the American Nurses Association (ANA) established nursing informatics as a distinct profession in the year 2001. This profession combines nursing with computer and information technology in order to better serve patients. The goals of nursing informatics include the management of data and the expansion of nursing knowledge (Darvish et al., 2014).

The field of nursing informatics is acquiring more notoriety in today’s culture as a direct result of developments in information technology. The vast majority of healthcare systems are currently using various technological advancements in order to simplify and enhance the effectiveness of their operational procedures. It is the responsibility of the nurse informaticist to advance communication and information technology within the healthcare industry. Electronic medical records and computerized provider ordering, for example, make it easier for medical personnel to obtain information in a timely manner, make use of it to improve patient safety and reduce the number of medical errors, expenses associated with healthcare, and delays in patient care. Additionally, they are employed in the fields of teaching, research, chief nursing officer positions, and software engineering. The informatics nurse is responsible for supervising all of the complicated technological tasks that are tied to the care and safety of patients, enhancing their knowledge and skills, and utilizing information technology to assist in the care of patients.

Collaborative effort amongst organizations from various fields of study

The task of developing efficient collaboration and communication technology has been given to teams of healthcare professionals from a variety of backgrounds. So, the most important job that these teams have is to enhance communication. When a healthcare company has nursing informaticists on staff, the company is able to improve the way that technology is used. This, in turn, makes it easier for nurses and other healthcare professionals to collaborate, which in turn boosts the efficiency of the operations of the healthcare company.

According to the essay that Green and Thomas wrote, technological platforms such as electronic medical records might lend a hand to medical professionals in the delivery of care that is both reliable and of the highest possible standard for patients. Because of this, it is absolutely necessary for medical doctors, nurses, and other professionals in the healthcare industry to collaborate with those who specialize in technology in order to design an effective electronic healthcare system (2008). The nursing informaticist works together with the other nurses and the team responsible for information technology to investigate and investigate new and emerging technologies in search of ways to improve the efficiency of the documentation process (Zareshahi et al., 2022). They achieve this by utilizing a computer, voice recognition software, and a variety of other technologies, which allows them to improve the accuracy of the documentation, decrease the amount of labor that is not needed and make it possible to record notes earlier and more rapidly. In addition, nursing informaticists are responsible for educating clinical nurses on how to use and engage with data entry systems, including how to maintain records and address concerns related to technology. The nursing informaticist is accountable for engaging in active listening with the purpose of recognizing problems and cooperating with pertinent persons or departments in order to recognize possible solutions (Green& Thomas, 2008).

The Essential Role of the Nurse Informaticist in the Healthcare Industry

The healthcare sector is plagued by a multitude of problems, many of which might be alleviated with the implementation of cutting-edge technologies like information and communication technology. These technologies may be of assistance to healthcare organizations in their efforts to save costs and shift patient care away from institutional settings and towards home care. For instance, mobile health devices, wearable technology, telemedicine, and electronic health records have all become increasingly crucial for the purpose of assisting physicians, in addition to monitoring remote patients and providing home care. The implementation of nursing informatics has a bearing on the clinical work that nurses do. A nursing informaticist contributes to the facilitation of these systems by integrating the data, information, and knowledge that patients, nurses, and other healthcare practitioners require to assist them in making decisions. This information is necessary for patients, nurses, and other healthcare practitioners. The work that they conduct on a daily basis is being impacted by the technologies that are associated with informatics. Nursing informaticists aid other medical professionals, such as physicians and nurses, in better-comprehending information structures and procedures in order to ensure that patients receive the highest degree of care that is humanly possible (Warm & Thomas, 2011). “Nursing Informaticists are responsible for facilitating the gathering, management, and processing of pertinent data in order to utilize information and develop knowledge that supports nursing in all practice domains,” says one definition of the profession. Page 36 of the version of Warm & Thomas published in 2011 As a consequence of this, healthcare organizations and providers are now able, with the assistance of nursing informaticists, to collect and analyze patient data in a manner that is both more accurate and effective, and to provide patient care in a manner that is both more efficient and more effective on a day-to-day basis.

Evidence Based-Practice Strategies in the Protection of Health Information

It is becoming increasingly important to protect patient’s privacy and confidentiality within healthcare organizations as a result of the increased integration of advanced technology in healthcare; however, it can be difficult to keep a working knowledge of current and predicted security threats up to date. Within computerized health information systems, the means of communication and the sharing of information are simplified and automated, which raises the risk that protected health information will be unlawfully transferred. The confidentiality of information relating to patients, staff members, and other associated persons is required by law to be upheld by organizations that provide medical treatment and the workers employed by those organizations. As a consequence of this, the Patient Privacy and Confidentiality Act needs to be obeyed in order to guarantee that the role that nurses and interdisciplinary teams play in the process of legally protecting patient information and health records is done so in accordance with the law. The information that is shared between medical professionals over the course of a clinical encounter is regarded as confidential and must be protected at all costs. The patient has the legal right to read the information that is stored in their medical record as well as the right to obtain a copy of that information. It is only permissible for healthcare teams to divulge patient information to unaffiliated third parties with the patient’s prior consent or in compliance with the requirements of the law. Nonetheless, if data is necessary for the patient’s treatment, payment, or administrative procedures, it may be disclosed even without the patient’s permission.

The strategy of regulating access, choosing what level of information must be provided, and providing each individual user with their own user name and password in order to get entry. In addition to a username and password, biometric identification methods like fingerprinting, iris scanning, face recognition systems, and voice recognition software are ideal for limiting access to sensitive patient information and ensuring that an electronic signing procedure is carried out correctly. Biometric identification methods include fingerprinting, iris scanning, face recognition systems, and voice recognition software (Samadbeik et al., 2015). Passwords can be made more secure in a few different ways: regulating that they are changed after a particular period of time, requiring a specific minimum number of characters, and limiting the number of times that a password can be used more than once. Each of these steps requires the collaboration of a multidisciplinary team of healthcare professionals, such as nurses, pharmacists, doctors, information technicians, and nursing informaticists, in order to protect the privacy and confidentiality of patient information. It is recommended that the relevant information and guidelines about the security system be disseminated through the means of education, consultation, and the performance of staff functions, respectively. In addition, it is advised that nursing informatics work together with a variety of stakeholders to build an effective plan for improving electronic nursing documentation (Samadbeik et al., 2015).

Scoring Guide

Nursing Informatics in Health Care Scoring Guide

CriteriaNon-performanceBasicProficientDistinguished
Define nursing informatics and the role of the nurse informaticist.Does not define nursing informatics and the role of the nurse informaticist.Defines nursing informatics and the role of the nurse informaticist, but the description lacks detail or is missing important information.Defines nursing informatics and the role of the nurse informaticist.Defines nursing informatics and the role of the nurse informaticist. References current data, evidence, or standards to support and refine definition.
Explain how the nurse informaticist collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care.Does not explain how the nurse informaticist collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care.Identifies but does not explain how the nurse informaticist collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care.Explains how the nurse informaticist collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care.Explains how the nurse informaticist collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care. Makes explicit reference to scholarly or professional resources to support explanation.
Justify the need for a nurse informaticist in a health care organization.Does not justify the need for a nurse informaticist in a health care organization.Proposes but does not justify the need for a nurse informaticist in a health care organization.Justifies the need for a nurse informaticist in a health care organization.Justifies the need for a nurse informaticist in a health care organization and references relevant and timely scholarly or professional resources to support the justification.
Explain evidence-based strategies that the nurse informaticist and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality).Does not explain evidence-based strategies that the nurse informaticist and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality).Describes but does not explain evidence-based strategies that the nurse informaticist and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality).Explains evidence-based strategies that the nurse informaticist and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality).Explains evidence-based strategies that the nurse informaticist and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality), with reference to specific data, evidence, or standards to support the explanation.
Follow APA style and formatting guidelines for citations and references.Does not follow APA style and formatting guidelines for citations and references.Partially follows APA style and formatting guidelines for citations and references.Follows APA style and formatting guidelines for citations and references.Follows APA style and formatting guidelines for citations and references with flawless precision and accuracy.
Create a clear, well-organized, and professional proposal that is generally free from errors in grammar, punctuation, and spelling.Does not create a clear, well-organized, and professional proposal that is generally free from errors in grammar, punctuation, and spelling.Creates a proposal that lacks clarity and/or has errors in grammar, punctuation, and spelling.Creates a clear, well-organized, and professional proposal that is generally free from errors in grammar, punctuation, and spelling.Creates a clear, comprehensive, well-organized, and professional proposal that is error-free in grammar, punctuation, and spelling.

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