Evaluation Of The Electronic Health Record ( Ehr ) Essay

Evaluation Of The Electronic Health Record ( Ehr ) Essay

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Four activities in the nursing process that are defined within meaningful use and have been observed in clinical rotations include code status, such as allow natural death (AND), diagnostic labs, health history, and increased patient safety documentation. Documentation into the electronic health record (EHR) can be very challenging. These four activities or nursing processes are part of the stages within meaningful use criteria. Code status involves the patient and family in their health care. Involving the patient in their health care is part of stage one in meaningful use (HealthIT.gov, 2013). Diagnostic laboratory testing is also part of stage one by using information to track the patient’s condition (HealthIT.gov, 2013). The health history involves more patient reported data, part of stage two (HealthIT.gov, 2013). Increased patient safety documentation leads to increased patient safety and outcomes in stage three of meaningful use (HealthIT.gov, 2013).
One of the first things that I observed nurses in a hospital setting ask in report or looking up in a patient’s chart once they obtain their assignment for their shift is the patient’s code status. The EHR chart provides essential information on the patient’s dashboard (Alexander, 2015). Code status empowers the patient and family to decide what life saving measures they do want or do not want in the case of imminent death. Engaging the patient and their family is in stage one of meaningful use (HealthIT.gov, 2013). An AND, for example, engages the patient and family on the difficult decision to not resuscitate in the event that the patient stops breathing or goes into cardiac arrest. An AND noted in the EHR passes along the continuity of care to all health care individuals acc...


... middle of paper ...


...he EHR can help nurses maintain continuity of care, provide information for care coordination, and insure safer and better patient outcomes.


Meaningful Use Criteria
Example
Using information to engage patients and their families in their care (Stage 1)
Code Status
Using information to track key clinical conditions (Stage 1)
Diagnostic Laboratory Tests
Patient-controlled data (Stage 2)
Health History
Improving quality, safety, and efficiency, leading to improved health outcomes (Stage 3)
Documentation of Safety Measures

Reference
Alexander, S. (2015). The Electronic Health Record In S. Alexander, K. H. Frith & H.
Hoy (Eds.), Applied Clinical Informatics: For Nurses (pp. 199-219). Burlington, MA: Jones & Bartlett Learning.
HealthIT.gov. (2013). EHR Incentives & Certification. Retrieved from
https://www.healthit.gov/providers-professionals/how-attain-meaningful-use

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