Nursing And Electronic Medical Records

In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system.

The EMR is a software program used to enter patients information into a computer, which organizes and stores the information. I believe most offices will keep the paper charts in a very safe location or shred it. But I think because of the confidentiality that any and all information or records relating to patients is considered privileged. basically saying keeping all information about the patient confidential.

Nursing informatics and technology are quickly becoming the hot buzz words for nursing in the twenty-first century. While performing research for this specific paper, the observations of how far technology has come from its inception is mind boggling. When looking back to the mid 1990’s every patient had paper charting. Nurses manually charted vital signs, nursing notes, treatments and all orders were manually written in the chart. The patient’s name, insurance information, and billing items were stored electronically. Fast forward twenty plus years and everything nurses do with, for or to a patient is filed electronically. This file today is known as the electronic health record (EHR) (Lavin, Harper, & Barr, 2015). This paper will be delving into the history of nursing informatics and technology, the pros and cons for nurses and what will be the big picture for informatics and technology in nursing today and in the future. Nursing informatics and the technology that has evolved over time are changing and quickly affecting how nurses treat, communicate, plan and document everything that they do for their patients.

Within the Electronic Health Record program, the nurse has access to evidence-based practice tools that can assist the nurse in making decisions regarding the patients plan of care (Linder, J., Bates, D., Middleton, B., & Stanfford, R., 2007). The most important feature of the Electronic Health Record is the ability to instantly provide real-time patient-centered data to all authorized providers (HIT, 2013). The Electronic Health Record is real-time, providing nurses with the most up to the moment patient information the significance of this feature can be explained in the following example. For example, if a patient is in surgery, the patient's health record is available to the circulating nurse in the Operating Room, the Post Anesthesia Care Unit nurse and can be shared with the unit staff nurse the patient will be transferred to after recovering in the Post Anesthesia Care Unit. This is of particular importance because having access to the patient's chart, allows the nurses at each phase on the patient's care the ability to prepare supplies, gather necessary equipment and arrange for supplementary staff. Evidence-based practice suggests appropriate planning is a key factor in promoting positive, cost efficient patient outcomes (Anderson, 2012). In the profession of nursing when time is of the essence, and time loss can mean loss of a life, this is a feature that is very

The Role of Electronic Health Records and Health Information Exchange in the Delivery of Quality Healthcare

The Inner City Clinic is experiencing problems with medication prescribing errors and seeks a resolution to this problem through use of electronic medical records and registration medication reconciliation. The Institute of Medicine reports in the work entitled "Preventing Medication Errors" that the "average hospitalized patient is subject to at least one medication per day. This is reported to confirm previous research findings that medication errors represent the "most common patient safety error." (Barnsteiner, nd, p.1) Medication reconciliation is described as follows:

Healthcare can be known for a complex industry. Every day is a new day facing complicated clinical administrative transactions with electronic medical records and safety? Health Information technology is suppose to realize errors using electronic medical records. Leaders must understand the complexity and safety issues in order to help mandate electronic medical records with design, development, implement and use. In the last decade, this article has informed executives, clinicians, and technology. Their main focus was on these three areas computerized physicians order entry. Their main focus was to work all three areas computer physician order entry, computer decision support system,

In the modern world technology is everywhere and it affects everyone’s daily life. People are constantly attached to cell phones, laptops, and other electronics, which all have affected how people live their lives. Technology is also a large part of the healthcare system today. There are many electronics and technologies that are used in health care, such as electronic health record, medication bar code scanning, electronic documentation, telenursing, and there are many more forms of technology that impact nursing. One technology that stands out is the electronic health record. The electronic health record, also referred to as EHR, is an electronic version of a patient’s chart, and it contains is a list of the patient’s current medications, allergies, laboratory results, diagnoses, immunization dates, images, treatments, and medical history (“Learn EHR Basics,” 2014). The purpose of the electronic health record is to have a patient’s health care record available to health care providers nationwide, but the patient can decide who has access to their record (Edwards, Chiweda, Oyinka, McKay, & Wiles, 2011). The electronic health record is a very important technology in health care and it impacts nurses, nursing care, and has a significant impact on patient outcomes.

With the increasing advances with technology in this day in age, there is no surprise that electronic health records will soon be a major component in all hospitals of the Canadian health care system. Assessment of Electronic Health Record Usability with Undergraduate Nursing Students is an informative article, written by Jones & Donelle, about the increased use of electronic health records within our system and discusses its benefits, as well as difficulties nursing students experience with this new type of technology. It is a new method of technology that will soon replace paper charting and will allow access to patients to communicate with their health care providers, manage their health information, schedule appointments, and have access

With the rapid growth in the implementation and use of electronic medical records, there is an increase in how we define the role of nurses and other team member’s (Deese & Stien, 2004). Along with providing optimal care, nurses are also responsible for interpreting and accurately documenting large amounts of information. According to, (Ericksen, 2009) nursing informatics is defined as the integration of nursing, its information, and information management with information processing and communication technology to support the health of people worldwide. In this

As Electronic Health Records (EMR) become part of the Nursing world, nurses must continue to be educated on the standard of care. Since nurses have the most one on one with the patients, we have to be involved and heard as the changes take place. Nursing must stay engaged in this evolution and help shape its direction, as it has already proven to have a significant impact on our practice and our patients (Dee McGonigle, 2012). We must be leaders in this process so we can provide our patients with the proper information and educate them about their care. Its known that informed patients have better outcomes and pay more attention to their overall health (Susan McBride PhD, 2012). If wisely implemented, HIT may eventually free up more time for

I still remember the days before EHR were started. I was working as a Health Unit Coordinator, and was responsible for getting the patient’s charts together and all the required forms that will be used for the patient doing there admission. The charts were broken down upon patient discharge, and sent to medical records. The charts would have to be requested again from medical records in the event that the patient was admitted again at a later date, and the physicians and nurses would have to go through the charts to review the patient’s history. Health Care has come a long way since then. In this paper there will a discussion and examination on the current use of electronic health records and its relationship to health care. All of the providers and nurses that are responsible for the patient’s care, are able to review and share information on the patient. Any nursing care information that is beyond the basic compliance data, is not often included in the data that is being stored though EHR Today, nursing care data, beyond basic compliance data, is very seldom included in this data which is being stored electronically, even though there are studies that showing that including nursing problems will improve the accuracy of healthcare cost and patient outcomes. Welton, Halloran, and Zone-Smith (2006). By

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

Technology and innovation have transformed the way people function personally and professionally. In the past, writing and mailing a letter was standard but now most people send electronic messages and text messages to phones. Healthcare has been changing tremendously as well, not only are paper charts and records becoming obsolete, but now many facilities are sharing test results, visit information details, and prescribed drug lists. This move into the digital age has helped improve healthcare by cutting costs in the long-term, increasing efficiency with decreased wait times, and reducing medical errors. This evolving technology expansion, commonly referred to as nursing informatics has created many

As technology has and continues to advance so will the expansion of nursing informatics. Data from (19th annual 2008 himss leadership survey, 2008) hold this statement true showing a steady increase in the implementation of technologies. As computers became smaller, it became easier and efficient for hospitals and physicians office to implement their use. (sutton, 2007)The first computers were large, expensive, and inefficient. Now, computers are compact, inexpensive, and efficient. The smaller technology allows for portability of information. PDA’s are small enough to fit in your pocket. With these small devices, you can look up a patients medication, drug interactions, side effects, and just about anything, you could think of to