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Physician Rounding Tool
One of the big challenges faced by nurse leaders today is finding the time to stay connected to patients and staff. Purposeful nurse leader rounding on patients is quickly becoming a best practice in hospital throughout the United States. When it is done well, it can have a positive direct impact on both patients and staff. It has been shown to improve both patient and staff satisfaction. It is an organized way for nurse leaders to be visible. This can lead to an openness that will build trust and facilitate communication. As a leader, you will learn what is working well on your unit and department, and where there may be need for improvement. The use of “care bundles” in the prevention of ventilator-associated pneumonia and other intensive care unit (ICU) complications have been increasingly used in critical care practice. However, the effective
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EHRs allow easy navigation through the entire medical history of a patient. Instead of pulling paper chart volume 1 of 3 to search for a lab result, it is simply a matter of a few mouse clicks. Another important advantage is the fact that the record is available 24 hours a day, seven days a week and doesn’t require an employee to pull the chart, nor extra space to store it. Adoption of electronic health records has saved money by decreasing full time equivalents (FTEs) and converting records rooms into more productive space, such as exam rooms. Importantly, electronic health records are accessible to multiple healthcare workers at the same time, at multiple locations. While a billing clerk is looking at the electronic chart, the primary care physician and a specialist can be analyzing clinical information simultaneously. However, patient information should be available to physicians on call so they can review records on patients who are not in their panel. Furthermore, it is believed that electronic health records improve the level of
For years now, the healthcare system in the United States have managed patient’s health records through paper charting, this has since changed for the better with the introduction of an electronic medical record (EMR) system. This type of system has helped healthcare providers, hospitals and other ambulatory institutions extract data from a patient’s chart to help expedite clinical diagnosis and providing necessary care. Although this form of technology shows great promise, studies have shown that this system is just a foundation to the next evolution of health technology. The transformation of EMR to electronic heath record system (EHR) is the ultimate goal of the federal government.
Thus, reducing administrative work gives an opportunity to clinicians to spend more time with their patients. Through health informatics, some medical procedures can be automated, saving money for the health care budget. Research by Blumenthal and Tavenner (2010) states that, “The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers' decisions and patients' outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers.
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
The nurse to patient ratio is unrealistic in many hospitals. In most cases it is almost impossible to give each patient the true amount of detailed care they really need. This is seen in most cases where there is one nurse assigned to 16 patients and each patient requires a different level of attention. Nurses are pressed for time, forcing them to cut corners, resulting in an increase in nosocomial infections and patient deaths. “The past decade has been a unsettled time for many US hospitals and practicing nu...
Hospital administrators will charge nurse leaders with ensuring that patient positive outcomes prevail while also controlling overhead. Nurse leaders are specially trained just for this task. Clinical Nurse Leaders are the experts that America’s patients will rely on to keep them safe and healthy in hospital settings.
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
Over the years, healthcare facilities have acted like a storehouse for patients’ medical records, uninterested and unable to distribute clinical data to anyone beyond their organization. The EHR, started in the 1960s under the name of "computerized-based patient record" (CPR), became known as "electronic medical records" (EMR) in the 1990s and today it is known as electronic health record (EHR).The target of the Department of Health and Human Services (HHS) is to incorporate the EHR and use it in a "meaningful" way to improve the quality, efficiency, and safety of patient care delivery; to engage patients in their personal health record; and to improve care coordination. Equally important, the "meaningful use" of the EHR system intends to build a bridge to other systems by creating an interoperability of health information while implementing quality care throughout. However, this interoperability can only be accomplished when the receiving system and the user fully understand how to apply these exchanges.
Encinosa, W. E., & Jaeyong, B. (2013). Will Meaningful Use Electronic Medical Records Reduce Hospital Costs?. American Journal Of Managed Care, 19eSP19-eSP25.
Safe nurse-patient ratio is a complex issue debated on for many years. Due to inadequate staffing registered Nurses are faced with high patient ratios, and nurse burn out everyday. According to the American Nurses Association, “Massive Reductions in nursing budgets combined with, the challenges presented by a growing nursing shortage have resulted in fewer nurses working longer hours for sicker patients. This situation compromises care and contributes to the nursing shortage by creating an environment that drives nurses from the bedside”. (2012) Through the nursing process, the essential role of the Registered Nurse is to assess, diagnose, and plan based on outcomes, implement and evaluate the effectiveness of nursing care. However, it is not realistic to thoroughly implement these core guidelines in a safe and effective way, when you are
Murphy J, Quillinan B, Carolan M. "Role of clinical nurse leadership in improving patient care." Nurs Manage 16, no. 8 (2012): 26-28.
I have soon come to realize how much more there is to nursing than just helping and healing. Nursing is not taking care of individuals it is caring for them. Caring is not only important when concerning nurse and patient relationships. It is important in every aspect of humanity. The culture of caring involves intervening programs that help to build caring behaviors among nurses. As nurses become stressed and become down on their life it has shown that caring for oneself before others is key in caring for patients. Also, throughout the years many theorists have proven that caring has come from many concepts and ideas that relate directly to ICU nursing. The knowledge I have gained from reading and reviewing these articles has and will help me to become a better nurse. It will help and provide the pathway for caring in my professional
Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
In healthcare it is very important to have strong leaders, especially in the nursing profession. A nurse leader typically uses several styles of leadership depending on the situation presented; this is known as situational leadership. It is important that the professional nurse choose the right style of leadership for any given situation to ensure their employees are performing at their highest potential. Depending on which leadership style a nurse leader uses, it can affect staff retention and the morale of the employees as well as nurse job satisfaction (Azaare & Gross, 2011.) “Nursing leaders have the responsibility to create and maintain a work environment which not only promotes positive patient outcomes but also positively influences teams and individual nurses” (Malloy & Penprase, 2010.) Let’s explore two different leadership styles and discuss how they can enhance or diminish the nursing process.
The nursing profession has changed drastically over time. The roles and responsibilities that nurses take on have increased and become far more complicated. Nurses are managers, leaders, supervisors and have become experts in many areas of care. Every day nurses are faced with the task of improving and strengthening professional leadership within their work environment. Managing good quality and eliminating risk is the major challenge in health care. All members of the team must work together to accomplish outstanding patient care. Budget cuts and nursing shortage in all areas of health care leads to less licensed staff, where use of unlicensed personnel have been used widely, where delegation is not an option, but a necessity. Nurses must be aware of delegation guidelines, what tasks to delegate,when to delegate for the safety of patients, liability of nurses and the facility.