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relevance of electronic medical records
important of electronic medical records
relevance of electronic medical records
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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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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
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.
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 federal government has encouraged EHR use in hopes that it will significantly improve patient care. There is the intent that electronic health records will allow any provider access to important patient health information no matter where the patient is, while “creating a comprehensive national electronic health information network that leads to a reduction in the duplication of tests, an improvement in the cost-effectiveness of interventions, and the ability to compile a comprehensive patient history” (McBride, Delaney, Tietze, 2012). While the implementation of EHR’s has good intent, an important question is, “How are the implementation of EHRs having an effect on emergency nursing and patient care?”
When walking into a hospital, nursing home, or physician’s office, electronic devices are used everywhere. The doctors have pagers, drugs are released from an apparatus similar to vending machines, and the patients are connected to intravenous pumps and monitors, while they lay on beds that move with the touch of a button. Everything seems to be electronic, except for patient charts. A new system, called eHealth, was devised that would make these patient charts electronic. The goal for electronic health is to unite all healthcare by making patient records available to all providers in order to improve the quality of care patients receive. eHealth can be adopted into hospitals, physicians’ offices, and even ambulatory services. A 2006 study found, “Ambulatory EHRs improve the structure of care delivery, improve clinical processes, and enhance outcomes” (Shekelle 61). With professionals working together, procedures, scans, tests, and even visits to the hospital can be eliminated and in turn reduce the hospital’s expenses. However, this reduction may not add up to the investment the facilities will have to make. Adopting this system will cost more the some facilities are able to spend. However, investing in eHealth is a risk hospitals should take to improve patient care. eHealth has to become affordable to all providers for healthcare to reach its full potential.
Healthcare is constantly changing with the intention of improving patient care. The Institute of Medicine (IOM) issued a report introducing five core competencies for health professionals, in order to improve the Untied States healthcare system: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics (Institute of Medicine of the National Academies, 2003). IOM proposes that if all five core competencies are utilized by health professionals, quality patient care can be achieved. The facility in which this nurse work, is in need of improving their charting system. The facility currently utilizes two different software systems for charting, in addition to
Working as a professional registered nurse in the hospital, I realized how nurses struggle to find balance between devoting the time charting on the computer and spending time taking care of the patients. Moreover, I’ve seen nurses where they get discouraged trying to find this balance between patients and charting. As a bedside nurse, I would love nothing, but to tend to the needs of my patients. The length of time consume on electronic charting all day, take the very essence of bedside nursing away from nurses, which is caring. Reducing the time of nurses being occupied on charting by eliminating redundant tasks while conforming to their standard, are the changes I would like to make. These are a few of the reasons why I wanted to pursue a degree in informatics. I would advocate for nurses everywhere and to become an instrument in providing them a better electronic health system to work on. Pursuing the degree in nursing informatics will benefit me in
The ASF at my precepting healthcare facility used multiple forms of nursing documentation including both hardcopy and electronic methods. Oftentimes the hardcopy nursing notes would be discarded after the information was entered into the Computerized Patient Record System (CPRS). The task to develop an effective electronic nursing note that would eliminate the need for duplicate documentation on hardcopy forms and decrease the amount of time spent charting was initiated.
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.
EMRs provide a common access point where clinicians and health care providers can review and document information about clients and their care. These records are essential to improving efficiency and increasing client safety (Electronic Medical Records, n.d.). Electronic reports are an enabling technology that allows medical practices to pursue more powerful quality improvement programs than is possible with paper-based records (Miller, Robert; Sim, Ida). Clinicians and clients do not have to worry about errors occurring due to the poor legibility of handwritten paper medical records. EMRs facilitate the continuity of care before, during and after hospitalization because all the data in one place. Think of the amount of time and money employees spend on phone calls, emails, and faxes ...
The IOM report warned that the nursing profession must change, or it would not be able to meet the growing demands that are emerging as a result of health reform, new technologies and an aging population. (George Washington University, 2013) Nurse face with the new opportunities and challenges in reforming future health system. Nurses play an increasingly important role in leadership Nursing health care field is in the process of developing advance information and management systems for the goal of patient center care. And collaborate with all health care team That explicates that nurses will require advance information skills in order to uses this
Over the past decade, technological advances have paved the way for nurses to provide, quality, safe, standardized and individualized patient care (Saba & McCormick, 2015). The use of the Electronic Health Records (EHR) to manage patient data is quickly becoming widespread in the healthcare industry. The emerging use of the Electronic Health Record, is transforming how nurses care for patients. By creating and implementing an electronic, comprehensive, standardized method of recording patient data, nurses can facilitate and coordinate patient care with members of the multidisciplinary healthcare team. The use of the Electronic Health Record will promote positive
Technology is stated as the scientific method and material used to achieve a commercial or industrial objective. To go one step further, nursing technology is using a tool to advance nursing practice. “The Institute of medicine identified that technology as a viable method of enhancing patient care delivery and improving staff productivity” Sensmeier, Horowitz (2003 page). Because inadequate nursing staff causes shortcuts to be taken, there are mistakes made that could have possibly been prevented. Errors by nursing staff were variously reported as being responsible for between 44,000 and 98,000 hospital deaths per year. Sensmeier, Horowitz (2003). Technology can have a large impact on nursing. In the past 5 to 10 years, computerized patient records have increased less than 10%. This number shows us that we are still not embracing technology to its full potential. Today in most hospital systems computerized electronic charting is being used. Many hospitals have many different systems for...
William Goossen’s theory can be applied in nursing practice to develop nursing informatics skills and knowledge, as well as develop technological system competencies among nurses to collect, process, retrieve and communicate pertinent information across health care organizations (Goossen, 2000). This theory is highly applicable in addressing matters related to electronic health records, which are currently characterized with issues of privacy and confidentiality in relation to storage, retrieval and reproduction of patient health information. The model also provides broad applicability in guiding research at any clinical setting and contributes to the discipline of nursing by simplifying and enhancing documentation and storage of patient’s health information and by allowing better utilization of nursing resources (Elkind, 2009).
Ragavan, V. (2012, August 27). Medical Records Pals Malaysia : 17 Posibble Reasons How Electronic Medical Records (EMR) Might Support Day-to-Day Patient Care. Retrieved from Medical Records Pals Malaysia: http://mrpalsmy.wordpress.com/category/emr/