How dose informatics enhance or hinder safety for patients? If informatics is used correctly in the nursing process it can create a work environment where there is little to no patient complications. When informatics is used as a workaround, patient safety can be at risk. Informatics in the health care industry can provide cohesive and effective patient charting. Effective patient charting includes the patient’s history, medical problems, medications, and assessments done by each nurse. Without adequate patient information before and during a hospital stay, it can easily cause complication to arise. There have been numerous studies on how informatics affects patient safety. Throughout this paper, three research articles will be discussed to …show more content…
Safety is the process of minimizing risk of harm to patients and providers through both system effectiveness and individual performance. Everything a nurse does is to prevent harm to a patient. That is not always just checking their vitals and giving them their medication on time. It is using your resources and to critically thinking about what I can do for this individual patient to help them reach their goal. A nurse dose more than just think about the patients illnesses, they think about a whole person. Using informatics can help a patient reach some of their goals. In the older population it is staying independent. Informatics can help a nurse reach a goal of helping a patient regain some mobility, or prevent a pressure ulcer from forming. Informatics helps the health care delivery system to function at a higher …show more content…
Patients that are admitted to the ICU tend to be more vulnerable to the occurrence of errors and adverse events due to the severity and gravity of their condition, a higher frequency of pharmacologic and therapeutic interventions, and the use of multiple technologic devices (de Sousa, Dal Sasso, and Barra 2012). If nurses’ records are not high quality with objective data that cover the patient’s condition, assessments done, intervention provided and how they were done, the patients outcome, and patients’ further needs. It will be difficult to treat a patient with inconsistent electronic health records. This can result in an error being made. Studies are showing that a need for standardizing data entries included in the electronic health record, as well as recover and analyze information by means of a vocabulary that standardizes the clinical terms of the care practice (de Sousa, Dal Sasso, and Barra 2012). The standardization of these clinical terms must meet specified criteria such as validity, specificity, data recovery and ease of communication, and must be presented in a way that supports the understanding, knowledge and intuition of the professionals (de Sousa, Dal Sasso, and Barra 2012). With standardized data entries in the electronic health record, it will facilitate communication between everyone caring for a patient. There would not be any more questions about what someone might have
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.
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).
Health informatics is best described as the point where information science, medicine, and healthcare all meet. It encompasses the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and the use of information in health and biomedicine. Health informatics incorporates tools such as: computers (hardware and softwar...
In order for hospitals and other health care facilities to prevent the thousands of deaths and injuries that occur every year due to medical errors; health care systems were required to implement new record keeping technology. This technology has made patient information and treatment accessible to all who needed to see it. This is especially important when a patient has more than one attending physician and their care relies on each doctor knowing what the other one has done, serving as the prime communication tool between doctors. If organizations do not centralize their technology and essentially their patient databases, the potential for duplicate work or inefficient patient care can exponentially increase. These high tech medical records can help protect physicians and hospitals alike against any lawsuits that may be filed on behalf of their patients. By correctly and thoroughly documenting all symptoms, illnesses, treatments, medication dosages, and diagnosis’ the doctor and health care providers can effectively prove what actions were taken with the patient, communicate with third party billers, and even use the gathered information for teaching purposes. Keeping a precise record of a patient’s medical treatment makes a large difference in many aspects of health care; especially when a negligence tort or claim is filed against the hospital and/or a doctor.
This nurse believes that if the appropriate monitoring of safety and security is implemented to protect confidentiality and quality of care that information technology (IT) in healthcare with continue to have a positive impact on patient care and outcomes. This nurse also believes that proper extensive training on these sophisticated systems is very important to patient safety and efficiency of care. With all the new advances in healthcare emerging it will be challenging but can only get better.
Errors caused by system problems can be prevented by working with your vendor to reset user preferences as needed. In order to preserve data quality and protect patient safety, it is very important that all medical records contain correct information for the safety and treatment of the patient. It is very important to note any cha...
In the late 1960s, the first computer systems were installed in hospitals (Murphy,2010). The computer systems started in the basements of hospitals and now are in every nursing unit. Nursing informatics allows for a more efficient and faster delivery of health care. Nursing informatics is a way of keeping patient information properly organized and creating patient care plans.
The first reason that these matters are important in using information technology in nursing is the presence of established legal guidelines how to improve the quality of patients’ care while keeping clients’ personal information confidential and protected. Furthermore, the legislation significantly affecting several aspects of healthcare system, such as the dissemination of information, protection of personal information, use of technical standards, and use of electronic signatures (Hebda,2013). Utilization of informatics within healthcare system implies the easier process of sharing information, decrease amount of
Boaden, R., & Joyce, P. (2006). Developing the electronic health record: What about patient safety? Health Services Management Research, 19 (2), 94-104. Retrieved from http://search.proquest.com/docview/236465771?accountid=32521
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 non-acute settings medical errors are usually caused due to the transitions of care. Challenges are present in long-term facilities when adopting new health systems because the lack of knowledge with the system. Information that does not get completed also can stir up a great deal of confusion. A clinical documentation tool is used in long-term facilities because they provide easy access to patient records (Yearman et al., 2015). Medicare reimbursement must complete minimum data set information within 14 days of patient admission.
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.
Yignesh Ramachandran states in an article that health informatics “manages all aspects of the effective and efficient planning, collection, organization, implementation, analysis and use of data to create information within the healthcare system.” It gives easier access of client information to the interprofessional team. This system can improve the quality of health care, lowers paperwork and increase productivity. It also decreases the interpersonal time with clients.
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
In health care, safety does not only pertain to the patient, but to all of the staff as well. Although this is important, it is critical that nurses are safe, since they usually interact with the patients the most. If a nurse does not follow correct safety and health practices, they may cause harm to the patient, which may end up in a lawsuit if the damage is bad enough. If safety measures are followed and nothing wrong happens, this saves the facility money and it could possibly gain money if the patients refer the facility to other potential customers. Every facility should have a policy pertaining to safety measures, and it should be reviewed as needed. One thing that nurses will need to know is how to properly use lifts and