Four Aspects Of Nursing Activities In The Nursing Process

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

Using key information to evaluate patient outcomes is in stage one of meaningful use (HealthIT.gov, 2013). Nurses review labs on their patients at the beginning of the shift to determine the patient’s trends and predict and prepare for what the doctor may order for the patient. Labs documented within the EHR help in the continuity of care and coordination of care. They are recorded and trended in the EHR during a hospitalization to monitor if the patient is improving. If need be, physicians can consult infectious disease or other areas of expertise to improve the patient’s outcome. Ideally, if the hospital or health care provider ordering the diagnostic lab tests participate in meaningful use, the patient would have access from the provider’s self management tools within their EHR. Patients can remotely access their health care records from home. With the chart at the patient’s fingertips, there should be no gaps in continuity or coordination of

Stage three of meaningful use focuses on improving the quality, safety, and efficiency of patient care ultimately improving patient outcomes (HealthIT.gov, 2013). On all of my clinical rotations nurses were sure to remind me of what safety documentation was detrimental. Additionally, the EHR helps nurses record activity as it occurs in real time (Alexander, 2015). I think this is not only important for covering the nurse and organization, but also to improve patient outcomes. If nurses are consistent with proper rounding and ensuring safety measures are met every time they enter a patient’s room, then document the measures taken accurately, safety sentinel events can be