Nursing Documentation And Informatics Paper

Discuss an original presentation to introduce the new EMR system to staff on you unit. In your Presentation:

* Reduction of medication errors- Barcode medication administration safeguards against wrong pt/wrong med/wrong dose errors and alerts to potential medication interactions (Goth, 2006).

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.

Implementation of a practice change requires the innovator to be able to describe the process of implementation, specifically addressing the methods utilized, with an assessment of the key components of the implementation plan. The Daily Safety Briefing (DSB) initiative does not gather new information, but it does present information in a new way. There is no requirement for subject consent, as safety reporting is already covered under the umbrella of a consent to treatment, which patients sign at the time of admission (Hughes, 2008). Existing safety reports will be summarized into a one page document that will be presented at the DSB.

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.

This process paper will evaluate the complex relationship between disease pathophysiology and how it has progressed to the patient’s current state of health. It will include a comprehensive discussion of chronic and acute problems leading to the patient’s hospital admission, a complete description of interrelationships and pathophysiology for all medical diagnoses, a comprehensive discussion of the client’s signs and symptoms and results of all diagnostic studies to the underlying pathophysiology, and a comprehensive listing of all medications ordered at the time of admission with explanations of why each was ordered and identification of the most common side effects which may

The orientation process for new hires lasts six weeks. The new nurse attends nursing orientation for one week and then is assign a preceptor on the unit for each shift. The DPCS introduces the new employee to their preceptor. This nurse works three weeks on the day shift, one week on the evening shift and one week on the night shift working with both medically acute rehabilitation patients and surgical patients. Nurses receive extra days of their orientation with patients that the nurse has limited clinical experience such as a nurse with postoperative experience will work more with the medically acute rehabilitation patients to practice new skills. For new graduates their orientation is individualize and can last from 8-16 weeks.

Today’s healthcare is changing, and more hospitals are commencing to go paperless using computers for both medical records and charting. Computers are widely accepted, in personal and professional settings. It is an essential requirement for computer literacy. Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing skills but also to become educated in computer technology. While electronic medical records (EMR’s) and charting can be an effective time management tool, some questions have been asked on how exactly this will impact the role and process of nursing, and the ultimate effects on patient safety and confidentiality. In order to

The use of informatics and technology have been really helpful in eliminating the use of paper in documenting care, however; it also came with its own challenges. At the nursing facility where I work we still use paper for medication administration record (MAR) but we use point click care (PCC) for all other documentations like the nursing notes, skin assessment and SBAR. The impact that these changes has on my practice is the fact it makes charting easier as oppose to writing, it also makes the information immediately available for the health care team.

The authors conclude that in order to collect data for meaningful use, one must get back to nursing basics to satisfy regulatory requirements. Under direction of a nurse informaticist, utilizing electronic health records helps facilitate this.

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

Sir, can you please step up to the glass, put your palm on the screen and follow the directions from the computer? This is where our future lies…in biometrics, computers, and science. Soon there will be no need to fill out tedious paperwork, to try to remember medications or past medical history. I know it exists in hospitals across America, I have seen it in action many times. Are we as nurses changing with the times? What is nursing informatics? Why is it important to me? How do I rate on the nursing informatics knowledge scale? What is my plan to increase my knowledge base? These questions should be at the forefront of every nurse’s thoughts. The information age has come crashing down on us from every possible angle in our lives, it

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

Nursing informatics is a branch of nursing or area of specialty that concentrates on finding ways to improve data management and communication in nursing with the sole objective of improving efficiency, reduction of health costs, and enhancement of the quality of patient care (Murphy, 2010). It is also described as a growing area of nursing specialty that combines computer science, information technology, and nursing science in the management and processing of nursing information, data, and knowledge with the sole objective of supporting nursing practice and research. Various nursing theorists have formulated various theoretical frameworks or models related to nursing informatics (Wager, Lee, & Glaser, 2013), and they are defined as a

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