Electronic Health Records: The Nursing Information System

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Clinical documentation has been used throughout healthcare to analyze care provided to a patient, communicate important information between healthcare providers and patients, and provide medical records that will help patients track their conditions. The Electronic Health Records (EHRs) have revolutionized the process of clinical documentation through direct care to the patient. This electronic health record is a new technology that helps maintain patient’s privacy. Both computers and EHRs can facilitate and improve the clinical documentation methods, which is beneficial for all patients, the care teams, and health care organizations. In this case, documentation improvement has a direct impact on patients by providing quality information. However, the new technological change can also address the health care system efficiencies that result from paper-based charting. Obviously, the implementation of electronic clinical…show more content…
In the healthcare environment, clinical documentation is the collection of information that refers to patient’s electronic health or medical record. There are many advantages of using informational health records, “health care environment is experiencing an explosion of knowledge that requires standardization to collect, store, achieve, retrieve, process, analyze, and exchange vast amounts of health data [1], (pg. 252).” In addition, the clinical documentation is important to collect medication orders, care plans, consults, laboratory data, and client outcomes. These records are used to facilitate structured communication between nurses and other health professionals to improve the delivery of quality care. Thus, clear communications throughout the healthcare organization is very important to the well-being of the customers and professionals that provide
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