Genres and forms allow writers in any specific field to establish credibility, creativity, and a general outline to adhere to when completing compositions. Genre and forms can be descriptive labels to explain what one writes and how one writes. Nursing is no exception to this. In the nursing field, writing tends to be very short, factual, and precise since most of the writing is accomplished through nursing charts or notes to doctors and other clinicians. Nurses working a twelve-hour shift are extremely busy, so most often nurse must write short and concisely due to the limited amount of down time presented when working a shift (Dexter). Frequently, many hospitals use an EHR, Electronic Health Record, to limit full sentence narratives from …show more content…
The genre of nursing compositions may also be considered scientific, research-based, or nonfiction.
Prior to the introduction of Electronic Health Records, patient records were hand-written by medical scribes and stored in “Medical Records”. Nurses or medical students would have to send one to “Medical Records” to obtain information that was needed. This process was extremely time consuming for the fast-paced world of medicine. Hand written records also caused issues with legibility and accuracy. Electronic Health Records arose in the healthcare field in the 1960s and 1970s, however efforts to properly use EHRs did not begin until the 1980s. The goal of an Electronic Health Record is to compile large amounts of information on the patient admitted to the hospital. The record can further be accessed without the use of multiple sources. The earliest attempts at creating Electronic Health Records were not the best simply due to systems and technology not becoming advanced enough in the 1960s and 1970s to hold such a monstrosity of information. As technological advances have become more prominent
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.
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
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
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
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 health industry has existed ever since doctors bartered for chickens to pay for their services. Computers on the other hand, in their modern form have only existed since the 1940s. So when did technology become a part of health care? The first electronic health record(EHR) programs were created in the 1960s around the same time the Kennedy administration started exploring the validity of such products (Neal, 2013). Between the 1960s and the current administration, there were little to no advancements in the area of EHR despite monumental advancements in software and hardware that are available. While some technology more directly related to care, such as digital radiology, have made strides medical record programs and practice management programs have gained little traction. Physicians have not had a reason or need for complicated, expensive health record suites. This all changed with the introduction of the Meaningful Use program introduced in 2011. Meaningful use is designed to encourage and eventually force the usage of EHR programs. In addition, it mandates basic requirements for EHR software manufactures that which have become fragmented in function and form. The result was in 2001 18 percent of offices used EHR as of 2013 78 percent are using EHR (Chun-Ju Hsiao, 2014). Now that you are caught up on some of the technology in health care let us discuss some major topics that have come up due to recent changes. First, what antiquated technologies is health care are still using, what new tech are they exploring, and then what security problems are we opening up and what is this all costing.
Advances in technology have influences our society at home, work and in our health care. It all started with online banking, atm cards, and availability of children’s grades online, and buying tickets for social outings. There was nothing electronic about going the doctor’s office. Health care cost has been rising and medical errors resulting in loss of life cried for change. As technologies advanced, the process to reduce medical errors and protect important health care information was evolving. In January 2004, President Bush announced in the State of the Union address the plan to launch an electronic health record (EHR) within the next ten years (American Healthtech, 2012).
The purpose of the Electronic Health Record is to provide a comprehensive, standardized and universal digital version of a patient 's health records. The availability of a patient 's digital health record provides health information and data for critical thinking and evidence based decision-making, aggregates patient data for quality assurance and research. The Electronic Health Record has been, "identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients health histories and as a secure method of providing more informed clinical decision making" (MNA, 2006).
In the article entitled How Men's Brains Are Wired Differently Than Women's, Tanya Lewis suggests that males and females share two very distinct structures in the brain region. It is not surprising that males and females function under two biological roles in the society, but it has been proven that the brain has a rather significant involvement in this. This article introduces physiological as well as anatomical ways in which the brain of a male differs from that of a female. While I agree with Tanya Lewis’ claims, the articles does not address how gender roles and personalities can be a result of differences in the brain structures of males and females. This reflection will gather valid studies that proves that, indeed, the differences in character and personality traits of males versus
Nursing is a medical profession that involves the care and management of patients majorly in the hospital setting. This paper seeks to illustrate the fact that nursing is both a science and an art. Nursing is a science because it involves evidence based practice, education of the public, lifelong learning for the nurse and administrative roles that are allocated to the nurses. Nursing is also an art because nurses depend on intuition, have the capacity to promote positive change, are understanding and culturally sensitive.
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
A person needs to be able to document numerous amounts of information in a neat and organized manner in the most accurate way possible. A nurse in the field needs to be able to organize medical records and provide the information needed to help improve the quality of health care to the patients. For providing the health care personnel with accurate information is important to delivering quality care to the patients and improve job performance of other nurses, doctors and other medical staff and
Writing clear, concise and readable notes is an aspect of a professional development for nurses. It demonstrates that the nurse has fully developed their academic writing skills effectively. The nurse’s piece of work depends not just on the content by how they express it. The top priority of the notes or documents is that it has to be clear and logically developed so that the health team and doctors are able to follow through what the nurse is trying to express. The aim of written communications is to convey thoughts and ideas clearly as possible to the healthcare professional and doctors. While reading the notes or documentation the person should not need to seek clarification or extra help in order to try to understand the writing. The nurse must give careful attention on how their work is structured and expressed, so that there won’t be any confusion or misunderstanding.
The art of nursing is defined as being mindful of what the patient needs emotionally and physically. In order to fully practice the true art of nursing, one must have compassion, a caring attitude, and good communication skills (Palos, 2014). Another definition of the art of nursing is having a personal connection between the nurse and the patient (Kostovich & Clementi, 2014). My personal interpretation of the art of nursing is to be aware of the patient’s specific needs; being physically present when they need you; respecting the patient and the family; and being gentle when delivering nursing care. The science of nursing on the other hand is having the knowledge, skill, critical thinking and evidence-based practice integrated with nursing practice (Palos, 2014). With this concept, a nurse must have a good understanding of various types of diseases and be able to identify the symptoms associated with it. Medicine is an important part of science. Knowledge about the different drugs and knowing how to safely administer them are crucial in nursing care. Performing medical procedures and updating current nursing skills according to new evidence-based research is critical to achieve best patient outcome. A nurse should employ critical thinking skills and good decision making as well. My own definition of science of nursing is providing safe
Ragavan, V. (2012, August 27). Medical Records Pals Malaysia : 17 Posibble Reasons How Electronic Medical Records (EMR) Might Support Day-to-Day Patient Care. Retrieved from Medical Records Pals Malaysia: http://mrpalsmy.wordpress.com/category/emr/