Electronic Medical Records and Charting

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Electronic Medical Records and Charting

Today’s healthcare is changing, and more hospitals are commencing to go paperless using computers for both medical records and charting. Computers are widely accepted, in personal and professional settings. It is an essential requirement for computer literacy. Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing skills but also to become educated in computer technology. While electronic medical records (EMR’s) and charting can be an effective time management tool, some questions have been asked on how exactly this will impact the role and process of nursing, and the ultimate effects on patient safety and confidentiality. In order to investigate these topics, I will be addressing the individual aspects of EMR’s that nurse’s use every day, how they affect collaborative care, and the impact they have on the nursing role.

In the Emergency Department at General Leonard Wood Army Community Hospital (GLWACH) manual paper charting is still used for charting most of the patient care that is per-formed; the exception would be any laboratory studies needed and any kind of radiology proce-dures that must be done. These orders are then put into the computer system, most often by the nurses. I had an opportunity to observe both positive and negative indications during my 72 hour preceptorship at the General Leonard Wood Army Community Hospital. Some of the positive of having EMR’s and electronic charting are that: they are pass code protected, allow access to in-formation quickly, legibility and organization aspects, efficiency of time, and allow for easy transfer of data which minimizes errors. If a patient comes in by ambulance, and is un...

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... Informatics & the EMR on ADVANCE for Nurses. ADVANCE for Nurses. Retrieved April 16, 2012, from http://nursing.advanceweb.com/Regional-Content/Articles/Nursing-Informatics-EMR.aspx

Dykes, P., Cashen, M., Foster, M., Gallagher, J., Kennedy, M., MacCallum, R., et al. (2006).

Serveying Acute Care Providers in the U.S. to Explore the Impact of HIT on the Role of

Nurses and Interdisciplinary Communication in Acute Care Settings. Journal of Healthcare Information Management , 36-44. Retrieved April 16, 2012, from http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=678742

Yee, T., Needleman, J., Pearson, M., Parkerton, P., & Wolstein, J. (2012). The Influence of Inte-grated Electronic Me... [Comput Inform Nurs. 2012] - PubMed - NCBI. National Center for Biotechnology Information. Retrieved April 16, 2012, from http://www.ncbi.nlm.nih.gov/pubmed/22411414

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