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Introduction 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.
Evaluation of a mobile shift report system on nursing documentation quality. CIN: Computers, Informatics, Nursing, 31(2), 85-93. doi:10.1097/NXN.0b013e318266cac3 Yun, L., Clifford, P., Bjorneby, A., Thompson, B., Vannorman, S., Won, K., & Larsen, K. (2013). Quality improvement through implementation of discharge order reconciliation. American Journal Of Health-System Pharmacy, 70(9), 815-820. doi:10.2146/ajhp120050
This facility offers veterans the convenience of having procedures performed safely outside of the inpatient hospital setting. 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. When beginning my process for change in the ASF, I used Lippitt’s Change Theory as guide.
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).
Medical Education, 40(8), Retrieved from http://0-web.ebscohost.com.lib.utep.edu/ehost/pdfviewer/pdfviewer?vid=12&hid=106&sid=265b8200-d816-4fa5-aa4f-f99400f42b76%40sessionmgr104 doi: 10.1111/j.1365- 2929.2006.02528.x National League of Nursing, NLN. (2006, May-June). Designing and implementing models. Retrieved from http://www.nln.org/research/LaerdalReport.pdf Smith, S., & Roehrs, C. (2009). High fidelity simulation: factors correlated with nursing student satisfaction and self confidence.
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Today’s healthcare is changing and more hospitals are switching over to go paperless using computers for both charting and medical records. Computers are widely accepted in personal and professional settings. It is an essential requirement for computer literacy for computers to stay in use. Numerous advances in technology during the past ten years require that nurses not only be knowledgeable in nursing skills, but also to become educated in computer technology (Hensen, 2008). While electronic medical records and charting can be an effective time management tool, some questions have been asked about how exactly this will impact the role and process of nursing.