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Advantages Of Implementing Electronic Medical Records
The EHR system allows the health care providers to save and retrieve patient’s data, promoting improvement in clinical, organizational, and societal o...
Advantages Of Implementing Electronic Medical Records
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1) Yes, the EHR has made patient preferences more visible because one of the uses of the EHR involves engaging patients as well as their families in the decision making for the care the client receives at the institution. (Bates & Gawande, 2003) Therefore, if patients and their families are included in their management they are able to voice their preferences and dislikes so that the plan of care is constructed in a way that the patients preferences are taken into consideration in an attempt to enhance the quality of healthcare the patient receives, consequently improving outcomes. Another use of the EHR that assists patient’s preferences to be visible is the ability for the system to store and maintain the patient’s active medication list. …show more content…
This should be done instead of reorienting the student when they attend each new clinical environment. This should be avoided because it does not allow them the opportunity to master a critical aspect of the healthcare system. An IS can be described as a catalyst to patient care as patients depend on their medical record when they seek medical attention. (McNeil, Elfrink, Piere, Beyea, Averill & Klappenbach, 2003) Hence, these records should be accessed in a timely fashion in order to assess, diagnose and treat the patient effectively. Additionally, Mastering the IS in a clinical environment is essential for a student inorder for them to be able to access, understand and apply evidence base practise throughout their career. (Staggers, Gassert, Curran, …show more content…
Subjective data is gained from patients verbal output. As we may know Subjective output is very necessary in order to assess, diagnose and treat a patient, as pain is describes as whatever that patient says it is (subjective). Consequently, the criteria that systems should be constructed in a way that valid and reliable data is collected in an efficient and effective manner will be compromised. (HIMSS, 2007) On the other hand, statistics has shown that most of a nurse’s time is spent on documentation and direct patient care lacks. (Hagland, 2015) Therefore if a nurse does not have to document it allows a higher success rate in terms of patient’s progress and out comes to be recorded. Additionally, more accurate diagnostic test such as vital signs will be gained since error is more likely to occur when a nurse is monitoring and recording rather than an information
Medical records are the most basic of clinical tools (Pullen and Loudon 2006) and their main importance is to serve as a form of memoir or aid in client and patient support. Medical records therefore provides essential evidence of care provision, thereby enabling effective communication between health care professionals, members of the multidisciplinary team and all clinicians as a whole.
The task of documentation is vital to nursing practice. Many times, however, this documentation is repeated in different areas of a patient’s chart. DiPietro et al. (2008) reported that 40% of the written documentation done by nurses was on personal paper at the patient’s bedside. This had to be copied into the formal patient record at a later time, resulting in double documentation. The reason nurses are forced to use this method of documentation instead of transcribing assessments directly into the chart is that this vital record of the patient’s information is often not readily available. Because several disciplines of the healthcare team require the chart throughout the day, there is no guarantee as to when the nurse may actually have access to it. Additionally, in almost all hospitals that utilize paper charting, the chart must travel with the patient when he or she leaves the floor for testing or procedures. This creates another roadblock to all members of the healthcare tea...
middle of paper ... ... The goals are to empower patients and their families, reduce health disparities, and support research and health data. The EHR can prevent medication errors, reduce long term medical costs, improve population health and through the Meaningful Use program the vision of this program is becoming reality.
To begin, there are numerous advantages throughout the EHR system. Considering this, enhancing patient safety is priority in the healthcare industry. Reminders, alerts, and pop-ups are just a few of the safety features an EHR can provide. These items can prevent medication errors, by alerting a nurse or physician of a blood sugar that is out of range, or a medication with too high of a potency, such as a wrong dosage amount. Reminders can be as simple as an immunization reminder to get a flu shot. Another example could be a drug interaction between NSAIDS such as i...
Portability can improve patient care. Patients no longer have to “tote” their cumbersome medical records around anymore. EHR’s give physicians and clinicians access to critical healthcare information in the palm of their hand, which ultimately leads to improved patient care outcomes. EHR’s also provide security to vital medical and personal healthcare information. Organizations like HIPPA defines policies, procedures and guidelines for preserving the privacy and security of discrete distinguishable health information (HHS.gov,
The main purpose of EHRs is to mainly exchange health information electronically to help improve quality and safety for patients. Four pros of EHRs is to provide accurate and recent information of the patients, allow for quick access to the patient records, share the health information securely, and make patient records and notes legible. These four points are important and necessary because the goal overall is to improve public health. Patient information should always be updated and current. Health professionals need to easily have access to patient records to either update them or verify the information. Also, health professionals can now avoid any discrepancies with electronic records verses when records were completely on paper.
Electronic Health Record (EHR) is a digital collection of patient health information instead of paper chart that captures data at the point of collection, supports clinical decision-making and integrates data from multiple sources in any care delivery settings. The health record includes patient’s demographics, progress notes, past medical history, vital signs, medications, immunizations, laboratory data and radiology reports. National Alliance for the Health Information Technology defines EHR as, “ an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more
Documentation is one of the vital components of ethical, safe and effective nursing practices that provide comprehensible image of the clients health status and their outcomes. As nurses we must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. This may include communicating the findings to the multi-disciplinary team.
Through this essential, I have been able to integrate biophysical, psychosocial, analytical, and organizational sciences into my area of practice as an educator. I learned to improve my advocacy and mentoring skills providing my students a non-judgmental learning environment. The clinical rotations often bring forth ethical dilemmas and through debriefing the students and this writer are able to advocate for the patient. Organizational and Systems Leadership for Quality Improvement and System Thinking are critical for improving quality patient outcome. The DNP program prepares the graduate to evaluate practice approaches based on scientific research findings. Because, I education student nurses; I have the responsibility to keep up with new best practices in healthcare, and transfer this knowledge to the students. Clinical Scholarship and Analytical methods for Evidence-based Practice, I have been able to develop a PIOCT question and review the literature of the value of simulation labs. However, my question may have to be reframed for there were few studies that demonstrate to the percentage of time spent in simulation versus transitional clinical rotation. Information system/technology and Patient Care Technology and patient Care Technology for the Improvement and Transformation of
It will come to pass in every nurse’s career that she will be caring for a person that for whatever reason cannot communicate verbally. The reason can be vast such as dementia or language barriers. One of the biggest challenges this creates is assessing the patient’s pain level. In 2001 a system was developed by a group of critical care nurses that has been widely accepted in many healthcare systems in the US and Canada. The Adult Nonverbal Pain Scale is an assessment tool that uses five specific categories in pain assessment. However, the accuracy of this system is a matter of debate between healthcare providers and patient representatives. In this paper I will examine and compare the various methods of pain assessment used by healthcare personnel today.
Studies have implied that, healthcare professionals who practice clinical features through EHR were far more likely provide better preventive care than were healthcare professionals who did not. (page 116). From 2004, EHR has initiated, even the major priority of President Obama’s agenda is EHR (Madison & Stagger, 2011). Health care administration considers EHR as the introduction of advanced technology which can improve patient satisfaction are can increase the financial incentives of the healthcare organization. Studies have pointed out that the federal policy is proposed to transform all medical records into EHR (Hebda & Calderone, 2010).
In turn, this enhances patient care and outcomes. This documentation will provide necessary patient data and will be accessible through the EHR. Nursing interventions performed and documented give valuable information to the patient’s health and outcomes since the health maintenance, follow -up and compliance will be trackable. When a patient established in our clinic is admitted to the hospital, the hospital is not able to access our EHR so it isn’t possible for them to see the patient’s current medications or diagnoses. However, the hospital is in our health system and our office is capable of logging in to the hospital’s system and seeing the patient’s inpatient records.
Patients usually describe their pain in a variety of ways depending on its intensity and its area of localisation (McCaffery and Pasero, 1999). Pain to the patient has a meaning and through the appreciation of this fact can nurses comprehend why the pain is there, what it showcases, and if could getter better or worse for the patient. The story told by the patient to the nurse assists him or her to feel the patient’s pain, what that pain means to the patient and what the patient has done to control the pain thus far (Rapport and Wainwright,
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
The principles of documentation is clear, confidential, accurate, complete and concise, objective, organized and timely. Using documentation nurses are required to legally and ethically keep all information in the patient record confidential. There is the Health Insurance Portability and Accountability Act, known as HIPAA, which helps gives patients a greater control over their health care record (). Precise measurements and times must be used as much as possible. Accuracy can be enhanced through point of care documentation (Craven, 2017). The accuracy of documentation can be view from three perspectives veridical reflection of nursing, comprehensive while through detail of a patient journey and finally clarity in usage terms (Britain Summer of Nursing). The accuracy part is the really vital part in documentation within nursing because it shows the complete reflection of the stages of care that was provided by the health care professionals to an individual. Next, when an individual is documenting it needs to be complete and concise and organized. Having the report done as so allows for any health professional to find any information quick as possible without having to search throughout the entire chart for answers. When reporting it needs to be in a chronical flow order of the information about the patient care and procedures being done, within the chronological