Registered nurses provide and coordinate patient care, educate patients and the public about various health conditions, and provide advice and emotional support to patients and their family members (Purdue) all within an eight-hour period not including the work the paper work. Nurses spend a vast amount of their time completing paper work and writing out care plans. A nurse is not a nurse unless they know how to write in several different forms. In order to be a successful nurse you must first be a good writer. In the process of becoming a nurse you learn to abbreviate many of the medical terms (Lane).
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.
Informatics impacts a nurse’s duties because of the technology utilized each day. The use of this technology developed transforms the nursing career because it improves patient safety, quality, and efficiency of care delivery (Sensmeier, 2010). Within the technology, nursing care is ultimately impro... ... middle of paper ... ...advanced extremely. Informatics will continue to advance and I plan to develop in the future as well. Works Cited Cipriano, P. F. (2011).
EHRs are “a real-time, patient-centered” records that make health information available promptly and bring any patients’ health information together in one place such as medical history, medications, diagnosis, laboratory test results, immunization records, allergies and even medical images, and many others. The use of electronic health records (EHRs) continuously increases. An ability to collect secure patient data electronically, and supplies the information to the providers upon a request is one of the features in EHR. The system can also bring together information from more than one health care organization and any past and current clinical services of the patient that helps the health care professionals in providing quality services. Within this scope, EHR benefits health care providers to enter orders directly into a computerized provider order entry (CPOE) system, provides tools in decision making like, alerts, reminders, and provides access to the new research findings and evidence-based guidelines (Wager, Lee, & Glaser, 2013, pp.
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.
Clinical Decision Support Systems: Decision support systems were first developed and implemented in the corporate world in order to support business management. In the past few years, these support systems have been integrated into health care organizations to provide a sharpened evaluation capacity to data warehousing and data mining. The refined data analysis ability can result in enhanced patient care and diagnoses through assessment of several symptoms, forecasting of some drug interaction results, and other factors. As decision support systems are increasingly integrated into health care organizations and facilities, they have become important elements of health care systems. Actually, clinical decision support systems have been crucial in helping advanced practice nurses to make informed decisions and provide quality health care.
The EHR’s purpose can be understood as a complete record of patient encounters that automates access to information. It has the potential to streamline the clinician 's workflow in a healthcare setting, while also being the principle storage place for data and information about the health care
Electronic Health Record Systems are rapidly changing the health care industry from a paper-based system to an automated system. These repositories of digitally stored healthcare information allow for more continuity of care by all providers having the ability to access an individual’s health record. The trends and issues in healthcare from the standpoint of managing patient information touch on areas such as medicine, management, and legal and information technology. With the healthcare industry advancing toward electronic records, there will be a high demand for professionals who can manage the automation of patient information and ensure its security. An assessment of environmental factors, both internal and external, that will affect the continued rollout of Electronic Health Record Systems is necessary for effective planning.
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. Adoption of Meaningful Use in Today’s Healthcare society The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009.
Name: LOVELYNE DALEY Introduction (min 100 words This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand.