As electronic health records (EHR) have been introduced and with the developments in health information technology, standardized terminologies have been developed. Standardized terminology is the organized and managed terms developed according to guidelines and accepted by an accredited body (Hebda, 2013). These terms, often referred to as controlled terminologies, ensure accurate and valid data collection. It allows data collected to be shared with other departments and facilities. Using the interoperable data collected can reduce omission errors and eliminate duplicate testing, therefore reducing healthcare costs. Standardized nursing terminologies captures nursing’s contribution and reflects the unique nursing care elements within the EHR. …show more content…
Standardized terminology used in the EHR allows organizations to comply with Meaningful Use. Reimbursement is based on the components of Meaningful Use. As Meaningful Use comes together with ICD-10 and performance based reimbursement, it is necessary for a common medical vocabulary. SNOMED CT has been in existence since 1965 and is accepted internationally. “The system enables computers to understand medical language and act on it through a large set of concepts and descriptions representative of many standard industry terminologies” (Levy, 2013). In a survey published in 2011, 1268 nurses were asked how familiar they were with standard terminology. Of that number of completed surveys, 61.6 % of the nurses reported they have no knowledge of or experience with SNOMED. I think they have probably used it more often than they realize with the use of electronic medical …show more content…
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. This is helpful when the patient comes in for a follow up after hospitalization as the provider can address the reasons for admission as well as any medication changes. Unfortunately, and medication changes or new diagnoses with ICD-10 codes must be input manually by our staff. The hospital has none of this information from prior to the patient’s hospital stay since they aren’t able to access our EHR so they must call and request any records that may be pertinent in treating the patient. When a patient sees another provider like ENT, psychiatry, orthopedist, neurosurgeon, etc., our clinic does not have access to the records and therefore are unable to incorporate any medication changes or health
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.
2. What are some of the advantages and disadvantages to having a standardized terminology within electronic health record
The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. This act encourages healthcare providers and healthcare institutions to adopt Meaningful use in order to receive incentives from Medicare and Medicaid. Meaningful use is the adoption of a certified health record system that acquires or obtains specified objectives about a patient. The objectives or measures are considered gold standard practices with the EHR system. Examples of the measures include data entry of vital signs, demographics, allergies, entering medical orders, providing patients with electronic copies of their records, and many more pertinent information regarding the patient (Friedman et al, 2013, p.1560).
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
Many new technologies are being used in health organizations across the nations, which are being utilized to help improve the quality of health care. Electronic Health Records (EHRs) play a critical role in improving access, quality and efficiency of healthcare ("Electronic health records," 2014). In order to assist in expanding the use of EHR’s, in 2011 The Centers for Medicaid and Medicare Services (CMS), instituted a EHR incentive program called the Meaningful use Program. This program was instituted to encourage and expand the use of the HER, by providing health professional and health organizations yearly incentive payments when they demonstrate meaningful use of the EHR ("Medicare and medicaid," 2014). The Meaningful use program will be explored including its’ implications for nurses, nursing, national policy, how the population health data relates to Meaningful use data collection in various stages and finally recommendations for beneficial improvement for patient outcomes and population health and more.
The implementation of electronic health records (EHR) continues to make an impact on nursing and patient care throughout the country. As a part of the American Recovery and Reinvestment Act of 2009, all public and private healthcare providers were required to implement electronic health records in their facilities by January 1, 2014. By demonstrating “meaningful use” of the electronic medical record, facilities are able to maintain Medicaid and Medicare reimbursement levels. Providers who show that they are meeting the “meaningful use” criteria during EHR use will receive an incentive payment from Medicare and Medicaid. “Meaningful use” is “using certified technology in EHR implementation to improve quality, safety, efficiency, and reduce health disparities; engage patients and families; improve care coordination; and maintain privacy and security of patient health information” (Centers for Medicare & Medicaid Services, 2013).
As a current student at Akron General Medical Center we are allowed access to their EHR, McKesson. However, before logging into their system or even stepping foot on the floor the importance of patient information and keeping it c...
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.
Over the past decade, technological advances have paved the way for nurses to provide, quality, safe, standardized and individualized patient care (Saba & McCormick, 2015). The use of the Electronic Health Records (EHR) to manage patient data is quickly becoming widespread in the healthcare industry. The emerging use of the Electronic Health Record, is transforming how nurses care for patients. By creating and implementing an electronic, comprehensive, standardized method of recording patient data, nurses can facilitate and coordinate patient care with members of the multidisciplinary healthcare team. The use of the Electronic Health Record will promote positive
Technology is stated as the scientific method and material used to achieve a commercial or industrial objective. To go one step further, nursing technology is using a tool to advance nursing practice. “The Institute of medicine identified that technology as a viable method of enhancing patient care delivery and improving staff productivity” Sensmeier, Horowitz (2003 page). Because inadequate nursing staff causes shortcuts to be taken, there are mistakes made that could have possibly been prevented. Errors by nursing staff were variously reported as being responsible for between 44,000 and 98,000 hospital deaths per year. Sensmeier, Horowitz (2003). Technology can have a large impact on nursing. In the past 5 to 10 years, computerized patient records have increased less than 10%. This number shows us that we are still not embracing technology to its full potential. Today in most hospital systems computerized electronic charting is being used. Many hospitals have many different systems for...
Journal Title: Impact of Health Information Technology on the Quality of Patient Care. Introduction: Our clinical knowledge is expanding. The researchers have first proposed the concept of electronic health records (EHR) to gather and analyze every clinical outcome. By the late 1990s, computer-based patient records (CPR) were replaced with the term EHR (Wager et al., 2009).
(Bronnert, Masarie, Naeymi-Rad, Rose, & Aldin, 2012)In this article, the authors have shown the important of interface terminology acting as a bridge that links the works of providers and the information that is interpreted and stored in electronic health record (EHR). The authors explain the definition of terminology as a set of descriptions used to represent concepts specific to a particular discipline. Each terminology has its unique purpose and attribute. Today, a single patient’s EHR requires many terminologies using different coding systems, which create the gaps in linking the clinical codes between those systems. Furthermore, providers are forced to use administrative coding sets, such as CPT, HCPCS, ICD-9-CM, which are used to support
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).
Democracy and the Separation of Church and State Democracy remains imperative to America, as it is the foundation of our government. It provides citizens with an easy way of changing their government, and democracy is fundamental to the selection of our leaders. But the question arises; what is essential to a thriving democracy? One can argue that a strict separation of church and state ensures successful democracy in America.
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