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Relevance of electronic medical records
Importance of electronic medical records
Relevance of electronic medical records
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Recommended: Relevance of electronic medical records
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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... Informatics & the EMR on ADVANCE for Nurses. ADVANCE for Nurses. Retrieved April 16, 2012, from http://nursing.advanceweb.com/Regional-Content/Articles/Nursing-Informatics-EMR.aspx
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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. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
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
Wynn, D., Kaufman, M., Montalban, X., Vollmer, T., Simon, J., Elkins, J., I Rose, J. W. (2010).
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.
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.
As we enter the era of technological advances in the healthcare system, nursing informatics has become an essential element in the practice of nursing, and according to the American Nursing Association (2008), the managing of date, information, knowledge and wisdom are relevant to nursing. Thanks to health information technology (HIT), which has a wide-range of tools for improving care quality, there has been a reduction in care disparities, and improvements in care outcomes, including patient and family experience. In Addition, the advances in communication and information sharing has made HIT, a critical instrument for addressing the threats to safety and quality during care transitions, since every nursing action relies on knowledge based
Kobau, R., Zack, M. M., Manderscheid, R., Palpant, R. G., Morales, D. S., Luncheon, C., et al.
Segal, E. A., Cimino, A. N., Gerdes, K. E., Harmon, J. K., & Wagaman, M. (2013). A
Vahey, C. D., Aiken, H. L., Sloane, M. D., Clarke, P. S., and Vargas, D. (2010 Jan. 15).
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Timpano, K. R., Keough, M. E., Mahaffey, B., Schmidt, N. B., & Abramowitz, J. (2010).
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).
Prior to this class I was able to understand how technology reduced paperwork but this class allowed me to understand that technology is more than just reducing paperwork. It is helping healthcare providers share patient information with other healthcare providers to provide better care for patients (subject to privacy), track their patient’s records (electronic medical records(EMR), and computer based patient records (CPR)), use monitoring devices to record measurements direct into EMR, allows automatic supply orders and billing based on inputs from the documentations and so much more. These advanced technologies are also helping nurses track and create a better care plan and better documentation to ensure the utmost quality
The nursing field has experienced plenty of advancements both in technology and medicine since the twentieth century. Not only have these advancements changed the face of nursing but have also become an intricate part of the field. Technology has the capacity to improve patient care and outcomes and is therefore of great importance to nursing. How nurses manage clinical workflows and how they deliver patient care have been completely changed by various innovations in software. The rationale used in selecting the topic of advances in nursing is that the world is fast evolving and so is the healthcare sector. Extensive analysis and synthesizing of knowledge, interpretation of information, research and innovations in nursing has been done over the years. It is interesting to have an in-depth look at what has been done by various influencers in the profession. Purpose of this paper is to demonstrate both technological and medical advancements in the nursing field.